Presented  by 
Wallin  W.  King,   D.   0, 


COLLEGE   OF   OSTEOPATHIC    PHYSICIANS 
AND  SURGEONS  •   LOS  ANGELES,  CALIFORNIA 


THE  JHIP 


AND    ITS 


n 


DISEASES 


•<^  *      BT 

V7P.  GIBNEY,  A.M.,  M.D. 

PROFESSOR    OF    ORTHOPEDIC    SURGERY    IN    THE    NEW    YORK    POLICLINIC  ;    ASSISTANT 

SURGEON    TO    THE    HOSPITAL  FOR    THE  RUPTURED  AND  CRIPPLED;    FELLOW   OF  THE 

NEW  YORK    ACADEMY    OF   MEDICINE  ;    FELLOW  OF    THE  AMERICAN  ACADEMY    OF 

MEDICINE  ;  MEMBER    OF    THE    NEW    YORK    PATHOLOGICAL  SOCIETY,   OF    THE 

MEDICAL  SOCIETY    OF    THE  COUNTY    OF  NEW    YORK,   OF  THE    NEW    YORK 

CLINICAL  SOCIETY,   OF  THE  PRACTITIONERS'  SOCIETY  Of  NEW  YORK; 

MEMBER    OF    THE    AMERICAN    MEDICAL    ASSOCIATION,     OF    THE 

AMERICAN  NEUROLOGICAL  ASSOCIATION,  ETC.,  ETC. 


BEBMINGHAM  &  COMPANY, 


28  UNION  SQUARE,  EAST, 
NEW  YORK. 


20  KING  WILMAH  ST.,  STRAND, 
LONDON. 


1884. 


5" 


COPTKIGHT,  1883, 

BY  BERMINGHAM  &  CO. 


OUT  Of 
GRATITUDE   TO  A   FRIEND 

AND 

ADMIRATION    FOR    AN    HONORED    MEMBER     OP     A     PROFESSION 
WHICH    RECOGNIZES    HIM    AS 

gin  2lutfjorfn> 

IN 

THREE     DISTINCT     BRANCHES     OF     MEDICINE, 
THE  WRITER  DEDICATES  THIS  VOLUME 
•  TO 

C.  MACNAMARA,  F.R.C.S.,  ENG. 

SURGEON  TO  AND  LECTURER  ON  SURGERY  AT  THE  WESTMINSTER  HOSPITAL, 

SURGEON  TO  THE  ROYAL  WESTMINSTER  OPHTHALMIC  HOSPITAL 

SURGEON  MAJOR  H.  M.  INDIAN  MEDICAL  SERVICE. 


PREFACE. 


For  nearly  thirteen  years  I  have  resided  in  the  Hospital 
for  the  Ruptured  and  Crippled,  all  of  my  time  being  devoted 
to  daily  service  in  both  the  in-door  and  the  out-door  de- 
partments. This  hospital  is  well  known  for  the  large  num- 
ber of  orthopedic  cases  that  come  under  observation  and 
treatment.  For  instance,  during  my  term  of  service  the 
annual  reports  show  that  up  to  the  present  time  2048  cases 
of  "  hip-disease"  alone  have  been  treated,  and  a  very  large 
proportion  of  this  number  have  been  under  my  own  ob- 
servation. 

The  hospital  is  further  known  as  an  extremely  conserva- 
tive institution.  Dr.  Jas.  Knight,  its  founder  and  surgeon 
in-chief,  has  been  led  by  his  extensive  experience  to  adopt 
a  plan  of  treatment  which  coincides,  in  many  respects, 
with  the  definition  I  have  elsewhere  given  of  the  term 
expectant. 

It  will  therefore  be  readily  seen  that  the  writer  of  this 
book  has  enjoyed  unusual  facilities  for  the  study  of  the 
clinical  history  of  bone  and  joint  diseases.  A  large  num- 
ber of  our  cases  in  the  wards  are  of  this  nature,  and  many 
remain  in  hospital  for  two  or  three  years. 

The  record  of  signs  and  symptoms  as  they  occur  has  been 
made  without  any  bias,  and  it  is  seldom  that  any  interpreta- 
tion even,  of  these  changes  appears  on  the  books.  My  aim, 
in  other  words,  has  been  to  picture  every  case  from  its 
beginning  to  its  close. 

Our  case  books,  which  now  number  several  volumes,  will 
show  how  well  we  have  succeeded,  and  they  will  show  too 
that  the  notes  have  been  made  by  or  at  the  dictation  of 
myself. 

My  observations  have  not  been  confined  especially  to 
cases  under  the  non-mechanical  treatment.  My  relations 
with  those  gentlemen  who  are  fully  committed  to  mechani- 
cal therapeutics  have  been  close  enough  to  permit  from 
time  to  time  personal  examination  of  their  own  cases  ;  and 


£V  PREFACE. 

many  of  these  cases  I  have  seen  and  recorded  my  diagnosis, 
with  reasons  therefor,  before  the  splints  have  been  applied. 
The  privilege  therefore  has  thus  been  afforded  me  of  study- 
ing this  disease  under  the  various  methods  of  treatment; 
and  the  fulness  of  my  notes  at  different  periods  as  the  cases 
progress  has  made  it  quite  unnecessary  for  me  to  rely  on 
impressions  not  based  on  fact. 

For  unusual  facilities  in  the  pursuit  of  my  studies  I  am 
under  many  obligations  to  my  very  good  friend  Dr.  Jas. 
Knight  the  distinguished  surgeon-in-chief  of  the  hospital. 

To  the  members  of  our  house  staff  Drs.  S.  M.  Taylor, 
H.  P.  Cooper,  and  H.  J.  Bogardus  I  am  very  much  indebted 
for  assistance  in  the  preparation  of  this  work  for  the  press. 

With  general  surgeons  I  have  likewise  had  many  oppor- 
tunities of  studying  the  results  of  operative  procedures. 

It  therefore  gives  me  much  pleasure  to  thus  publicly 
thank  Drs.  Taylor,  Judson,  Shaffer,  Yale,  and  Stillman  for 
privileges  extended  me  in  examining  their  apparatus  as 
well  as  cases  under  their  care;  Drs.  W.  T.  Bull,  C.  T.  Poore, 
Jno  A.  Wyeth,  F.  S.  Dennis,  and  other  surgeons  for  similar 
acts  of  kindness. 

I  feel  that  I  can  thus  present  a  pretty  accurate  picture  of 
the  clinical  features  of  bony  lesions  of  the  hip,  both  under 
the  expectant  and  the  mechanical  forms  of  treatment.  That 
such  a  book  is  needed  none  will  deny;  that  the  writer  of  the 
present  volume  has  succeeded  in  producing  such  a  book  my 
readers  will  decide. 

The  limited  time  at  my  disposal,  the  hard  work  of  hospi- 
tal life,  the  opportunities  that  city  life  affords  for  recrea- 
tion after  a  day  of  toil,  mental  and  physical,  must  be  my 
apologies  for  the  many  imperfections  contained  herein. 

V.  P.  GIBNEY. 

NEW  YORK,  November,  1883. 


CONTENTS. 


CHAPTER  L 
INTRODUCTION. 

FAGS 

The  present  status  of  therapeutics^Classification — Method  of  ex- 
amination— Schedule  for  final  results 18 

CHAPTER  II. 
THE  ANATOMY  OF  THE  HIP. 

Surface  anatomy — The  muscles  arranged  according  to  function — The 
fascia  of  the  hip — The  bursae  about  the  hip — The  ligaments — 
Synovial  membrane — The  articulation— Centres  of  development.  30 

CHAPTER  III. 

SPRAINS  AND  CONTUSIONS  OF  THE  HIP. 
Symptoms — Diagnosis — Cases  illustrative — Treatment. 50 

CHAPTER  IV. 

NEUROSES  OF  THE  HIP. 

Definition — Comparative  frequency — Case  of  neuromimesis — Diffi^ 
culties  of  diagnosis — Points  in  differentiation  between  neuroses 
and  bone  lesions — Treatment. , .  59 

CHAPTER  V. 
I.  RHEUMATISM  OF  THE  HIP. 

Reasons  for  recognition  in  nosology — Illustrative  cases — Elements 
in  diagnosis — Cases  showing  how  easily  error  may  arise — Prog- 
nosis— Treatment 74 

II.  CHRONIC  RHEUMATIC  ARTHRITIS  (MALUM  COXM  SENILE). 

Pathology — Cases  illustrating  clinical  history — Diagnosis — Treat- 
ment    85 


6  CONTENTS. 

CHAPTER  VI. 

COXO-FEMORAL  PERIARTHRITIS. 

PAGE 

Pathology — Fibrous  periarthritis  not  considered — Course  of  disease, 
with  cases — The  diagnosis  and  its  importance — Lesions  from 
which  differentiated — Simplicity  of  treatment 94 

CHAPTER  VII. 

BURSITIS   OF  THE   HlP. 

Bursse  most  frequently  affected  —  Causes  —  Diagnosis  —  Cases  — 
Danger  of  expectancy  in  ilio-psoas  bursitis — Treatment  and 
prognosis — Recapitulation no 

CHAPTER  VIII. 

ACUTE  PRIMARY  SYNOVITIS. 

Symptoms  illustrated  by  cases — The  synovial  origin  of  bone  diseases 

not  established — Blisters  and  poultices 121 

CHAPTER   IX. 
I.  ACUTE  EPIPHYSITIS  OF  THE  HIP. 

The  infrequent  use  of  the  term — Its  significance  and  value — Analysis 
of  cases  reported  as  diastasis — Diagnosis — Its  similarity  to 
syphilitic  lesions — The  incompleteness  of  cure — Treatment. .  . .  135 

II.   DIASTASIS  OF  THE  HEAD  OF  THE  FEMUR. 

Definition — Signs  and  symptoms — Traumatic  as  distinguished  from 
pathological — Rarity  of  the  former — Case  illustrating  difference 
of  opinion — Diseases  and  conditions  from  which  differentiated 
—Conclusions 146 

CHAPTER  X. 
I.  PERIOSTITIS  OF  THE  HIP. 

Definition — Pathology — Etiology — Clinical  history — Cases  illustra- 
tive— Diagnosis — A  mode  of  origin  of  chronic  ostitis — Value  of 
the  probe — Prognosis 153 

II.  MALIGNANT  DISEASE  OF  THE  HIP. 

The  most  common  form — Period  of  life  for  periosteal  sarcoma — 
Importance  of  early  diagnosis — Fatality. , . , , , , .  j§j 


CONTENTS.  7 

CHAPTER  XI. 

CHRONIC  ARTICULAR  OSTITIS  OF  THE  HIP. 
PATHOLOGY. 

PAGE 

Different  views — The  pathology  as  taught — Cases  to  illustrate  the 
bony  nature  of — Disposition  of  several  foci  to  become  involved 
—Distinction  between  terms  in  vogue — Conclusions 170 

CHAPTER  XII. 

ETIOLOGY  OF  CHRONIC  ARTICULAR  OSTITIS. 

Opposing  views  —  Definition  of  struma  —  Statistics  to  prove  the 
strumous  origin  of — Similarity  of  struma  with  syphilis — The 
possibility  of  a  non-strumous  origin — Is  joint  disease  a  cause  of 
strumous  diathesis  ? — Deductions 203 

CHAPTER    XIII. 

CLINICAL  HISTORY  AND  COMPLICATIONS  OF  CHRONIC  ARTICULAR 
OSTITIS. 

Division  into  stages — The  dependence  of  symptoms  upon  pathology 
— Cause  of  atrophy — The  hip-limp — Reflex  muscular  contrac- 
tion— Symptoms  and  signs  of  first  stage — Second  stage  defined 
— Third  stage  —  Complications  —  Dislocation  nearly  always 
pathological — Tubercular  meningitis — Lardaceous  degeneration.  227 

CHAPTER  XIV. 

DIAGNOSIS  OF  CHRONIC  ARTICULAR  OSTITIS. 
PART  I. — THE  FIRST  STAGE. 

Possibility  of  determining  initial  lesions — Diseases  from  which  to  be 
differentiated  —  Detailed  account  of  each  —  Cases  illustrating 
difficulty  of 268 

PART  II, — THE   SECOND   STAGE. 

Perinephritis — Primary  perityphlitis — Caries  of  vertebrae — Acute 
epiphysitis 306 

PART  III. — THIRD   STAGE. 

Traumatic  dislocation — Caries  of  pelvic  bone — Definition  of  rheu- 
matism  316 

CHAPTER  XV. 

THB  TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS — GENERAL 
CONSIDERATIONS. 

Modes  of  treatment — Nature's  cure — Is  it  the  best  ? — The  expectant 
treatment — Definition — Typical  cases — Results — Claims 32? 


8  CONTENTS. 

CHAPTER  XVI. 

TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS  WITH  CRUTCHES  AND 
HIGH  SHOE,  WITH  OR  WITHOUT  FIXATION. 

I.  THE  PHYSIOLOGICAL  TREATMENT  OF  DR.  HUTCHISON. 

PACK 

Its  simplicity — Difficulties  of  carrying  it  out — Results— Conclusion.  337 

II.    PHYSIOLOGICAL  TREATMENT  COMBINED  WITH  FIXATION  SPLINTS. 

Hamilton's  wire  gauze — Vance's  leather  splint — Pattern  for  same — 
The  Liverpool  method — Hugh  Owen  Thomas's  splint — Mode  of 
correcting  deformity — Analysis  of  cases 344 

CHAPTER  XVII. 

THE  TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS  BY  EXTENSION 
APPARATUS  WITH  OR  WITHOUT  MOTION. 

Bauer's  splint — Washburn's  splint — Hutchison's  splint — Taylor's 
long-splint — Taylor's  modified  splint — Shaffer's  lateral  screw 
— Sayre's  long  splint — Judson's  modification — Mode  of  applying 
splints  —  Willard's  splint — Sayre's  short  splint — Chance's  ap- 
paratus— Stillman's  sector  splint — Stillman's  brace  for  hip  and 
pelvic  deformity — Roberts'  elastic  tension  splint — Conclusions. . .  358 

CHAPTER  XVIII. 
OPERATIVE  TREATMENT  IN  CHRONIC  ARTICULAR  OSTITIS  OF  HIP. 

Drilling  trochanter  for  arrest  of  disease — Macnamara's  results — Ex- 
cisions— Incorrectness  of  statistics — Indications  for  operation — 
Mode  of  operating — Operations  for  relief  of  deformity — Barton's 
— Volkmann's  subtrochanteric  osteotomy — Conclusion 388 


TABLE  OF  ILLUSTRATIONS. 


FIG.  PACK 

1.  Bursae  in  Front  of  the  Joint 37 

2.  Bursae  at  the  Back  of  the  Joint 38 

3.  Front  View  of  Capsular  Ligament 39 

4.  Back  View  of  Capsular  Ligament 40 

5.  Ligamentum  Teres 43 

6.  Diagram  showing  the  Course  Pus  takes  in  Perforation  of  Ace- 

tabulum 45 

7.  Plan  of  Development  of  the  Femur  by  Five  Centres 47 

8.  Vertical  Section  through  Hip-Joint  of  an  Adult 48 

9.  Vertical  Section  through  H  ip-  Joint  of  a  Child 49 

10.  Round-celled  Periosteal  Sarcoma • 164 

11.  Acetabulum   and  Head  of  Femur,  showing  Discolored  Spot  on 

Latter 175 

12.  Specimen  of  Diaphyso-Epiphysitis 178 

13.  Vertical  Section  of  Proximal  End  of  Normal  Femur 183 

14.  Vertical  Section  showing  Foci  of  Disease 184 

15.  Section  of  Sound  Femur  in  Fricke's  Case 185 

16.  Section  of  Morbid  Femur  in  Fricke's  Case 185 

17.  Volkmann's  Case 186 

18.  Showing  Rapid  Destruction  of  Bone  in  Barwell's  Case 189 

19.  Mr.  Holmes'  Specimen  to  illustrate  Caries  of  the  Neck 190 

20.  From  Volkmann's  Colored  Lithograph,  showing  Exfoliation  of 

Articular  Cartilage 191 

21.  Caseous   Ostitis,   Remnants    of   Head    Neck  and   Acetabulum 

fused  together  in  Attempt  at   Repair,  Trochanter  displaced 

upward 192 

22.  Section  of  the  Sound  Femur  to  compare  with  Fig.  21 193 

23.  Changes  in  Acetabulum  in  the  Advanced  Stages 195 

24.  Abscess  from  Acetabulum 196 

25.  Section  of  Femur 197 

26.  The  Usual  Deformity  of  the  Third  Stage 255 

27.  A  Compensatory  Lordosis  of  the  Third  Stage 256 

28.  The  Real  Deformity  in  a  Case  of  Spontaneous  Cure  in  Third 

Stage 257 

29.  A  Goniometer 274 

30.  Mr.  Thomas's  Method  of  securing  Fixation  of  the  Body 275 

31.  Beginning  of  the  Second  Stage 308 

32.  End  of  the  Second  Stage 308 

33.  Articular  Ostitis  of  Both  Hips 335 


IO  TABLE  OF  ILLUSTRATIONS. 


34.  Hamilton's  Splint — Front  View 345 

35.  Hamilton's  Splint — Rear  View 345 

36.  Pattern  for  Leather  Hip-Splint 346 

37.  Dr.  Vance's  Leather  Splint 348 

38.  Wrenches  for  Orthopedic  Practice 350 

39.  The  Thomas  Splint — Front  View 352 

40.  The  Thomas  Splint — Rear  View 353 

41.  Mode  of  Correcting  Deformity  with  the  Thomas  Splint 354 

42.  Dr.  Bauer's  Splint 359 

43.  Dr.  Washburn's  Splint 359 

44.  Dr.  Hutchison's  Splint 360 

45.  Dr.  Taylor's  Mode  of  reducing  Deformity 361 

46.  The  Modified  Taylor  Splint 362 

47.  Long  Splint  used  by  Dr.  Sayre 363 

48.  Dr.  Shaffer's  Lateral  Screw 363 

49.  Dr.  Shaffer's  Lateral  Screw  attached  to  the  Taylor  Splint 364 

50.  Dr.  Shaffer's  Lateral  Screw  attached  to  the  Taylor  Splint 364 

51.  Dr.  Judson's  U-shaped  Attachment 365 

52.  Adhesive  Strips  prepared  for  Splints 366 

53.  The  Plaster  applied 366 

54.  The  Taylor  Splint  applied 368 

55.  Dr.  Taylor's  "Joint-Supporting"  Splint 369 

56.  Dr.  Willard's  Splint 370 

57.  Dr.  Sayre's  Splint 371 

58.  Mr.  Chance's  Apparatus 372 

59.  Dr.  Stillman's  Sector  Splint 373 

60.  Dr.  Stillman's  Splint  applied 374 

61.  Dr.  Stillman's  Brace  for  Hip  and  Pelvic  Deformity 376 

62.  Spring  for  Dr.  Roberts'  Splint 377 

63.  Dr.  Roberts' Splint  378 

64.  Dr.  Sayre's  Wire-Breeches 399 


THE    HIP  AND   ITS    DISEASES. 


CHAPTER  I. 

THE  INTRODUCTION. 

In  studying  any  subject  connected  with  the  science  of 
medicine  necessary  attention  to  detail  should  be  the  chief 
consideration.  And  in  a  subject  like  the  present,  when 
there  is  so  much  that  is  not  clear,  so  much  that  is  taken 
for  granted,  it  seems  to  me  that  the  diseases  of  the  hip  are 
certainly  worthy  of  extended  study. 

There  are  certain  points  about  these  diseases  that  I  claim 
to  have  made  myself  familiar  with  ;  there  are  certain  facts 
that  I  have  gathered  here  and  there  that  enable  me  to 
speak  with  a  positiveness  that  sometimes  borders  on  dog- 
matism. 

In  the  whole  range  of  surgery  there  is  very  little  that  is 
really  positive  on  this  subject.  Year  after  year  witnesses 
the  introduction  of  new  forms  of  apparatus,  new  methods 
of  treatment,  or  revivals  of  the  same  principles  in  old  ap- 
paratus, and  year  after  year  witnesses  the  failure  of  the 
same  to  meet  the  diseases  set  forth. 

Not  that  I  am  aiming  to  depreciate  the  progress  in  the 
treatment  of  joint  diseases,  but  there  are  certain  stubborn 
facts  that  cannot  be  overlooked. 

It  is  a  fact  that  physicians,  as  a  rule,  still  call  all  the 
lesions  in  or  about  the  hip,  whether  they  be  acute  or 
chronic,  hip-disease. 

It  is  a  fact  that  many  children  grow  up  to  adult  life  with 
short  limbs  and  stiff  hips. 


18  DISEASES  OF  THE  HIP. 

It  is  a  fact  that  an  exceedingly  small  number  of  cases 
of  what  is  looked  upon  as  "genuine  hip-disease"  get  well 
without  deformity  or  lameness,  let  them  come  under  the 
most  approved  mechanical  treatment  early  or  late. 

It  is  a  fact  that  the  lay  public  still  looks  with  disfavor, 
or  at  least  with  apathy,  on  the  mechanical  treatment  of  dis- 
eases of  the  hip. 

On  the  other  hand,  it  is  a  fact  that  the  majority  of  chil- 
dren in  the  better  walks  of  life  receive  mechanical  treat- 
ment when  their  hips  are  diseased. 

It  is  also  a  fact  that  the  orthopedic  surgeons,  with  few 
exceptions,  have  discarded  what  is  known  as  the  old  expec- 
tant method. 

My  earnest  endeavor  in  the  pages  of  this  book  has  been 
to  contribute  something  toward  the  classification  of  dis- 
eases about  this  articulation.  I  shall  feel  that  some  good 
will  have  been  accomplished  if  I  can  succeed  in  establish- 
ing at  least  two  grand  divisions  ;  if  I  can  set  on  one  side 
all  those  lesions  of  the  soft  parts,  without  and  within  the 
joint,  many  of  which  are  of  an  acute  nature  ;  and  on  the 
other  side,  that  lesion  which  gives  the  results  we  all  dread 
so  much — that  lesion  beginning  in  the  bones,  entering  into 
the  formation  of  the  joint,  and  known  as  "true  hip-disease." 

All  orthopedists  are  working  in  this  direction,  and  classi- 
fication is  becoming  nearer  perfect  as  diagnosis  and  path- 
ology are  more  closely  studied.  Mr.  Barwell  has  done 
much  to  simplify  the  study  of  joint  diseases,  and  in  his 
last  edition  such  terms  as  ostitis,  epiphysitis,  chondritis, 
in  connection  with  joints,  encourages  us  to  believe  that 
the  time  has  come,  or  is  rapidly  approaching,  when  we  can 
recognize  these  various  diseases  and  intelligently  direct 
treatment.  Diagnosis  is,  after  all,  one  of  the  most  im- 
portant steps  in  the  management  of  joint  diseases. 

The  anatomy  of  the  hip  is  stereotyped,  and  very  little 
can  be  given  that  is  not  found  in  Gray,  Quain,  and  Morris. 
Indeed,  the  chapter  I  have  introduced  is  merely  a  compila- 
tion from  text- books,  and  I  lay  no  claim  whatever  to 
any  originality.  But  for  the  need  one  always  feels  of 
anatomical  knowledge  in  studying  surgical  diseases,  I 
should  not  say  anything  about  the  anatomy  of  the  hip.  Much 
that  is  not  found  in  the  ordinary  text-books  is  found  in 
Morris,  on  the  "  Anatomy  of  the  Joints,"  and  as  this  valuable 
work  is  unfortunately  not  found  in  many  American  libraries 


THE  INTRODUCTION.  19 

I  make  no  further  apology  for  the  reproductions  to  be  found 
in  the  next  chapter. 

In  the  chapter  on  Sprains  and  Contusions  an  effort  has  been 
made  to  render  the  diagnosis  easy,  and  some  suggestion  as 
to  prognosis  I  have  ventered  to  make,  although  at  variance 
with  popular  teachings.  The  impression  prevails  among 
the  laity,  and  the  profession  as  well,  that  a  sprain  or  a  contu- 
sion of  a  joint  are  serious  accidents  and  far-reaching  in  their 
results.  The  introduction  of  a  few  cases  from  the  large 
number  that  have  come  under  my  own  observation  clearly 
contradicts  this  impression,  and  I  am  sure  they  will  suggest 
many  similar  cases  in  the  practice  of  other  physicians.  If 
I  do  not  make  one  point  strong  enough  by  way  of  excep- 
tion in  this  chapter,  I  want  to  emphasize  the  fact  that  I  am 
not  a  disbeliever  in  the  development  of  chronic  joint  dis- 
eases from  slight  injuries  occurring  at  a  time  when  the  sys- 
tem is  in  a  poor  or  vicious  state  of  nutrition.  Under  such 
circumstances  sprains  and  contusion  often  lead  to  grave 
joint  lesions.  During  a  convalescence  from  a  continued 
fever  or  from  any  of  the  exanthemata,  such  conditions  of 
the  system  may  often  be  found  to  exist.  When  any  injury, 
however  trifling  in  appearance,  occurs  at  such  juncture  an 
early  diagnosis  is  of  vital  importance,  and  the  treatment  by 
rest  during  repair  is  equally  important. 

Next  in  order  we  have  a  class  of  symptoms  that  are 
grouped  under  the  term  neuroses,  and  I  have  made  a 
chapter  on  Neuroses  of  the  Hip.  It  may  seem  that  such 
lesions  belong  to  neurology,  but  inasmuch  as  these  cases 
come  frequently  under  the  observation  of  the  orthopedist, 
and  questions  of  differential  diagnosis  come  up  for  settle- 
ment, I  have  deemed  it  highly  important  to  class  this  ail- 
ment under  the  diseases  of  the  hip.  We  hear  much  now 
of  hysterical  joints,  of  neuromimesis,  and  of  the  old 
Brodie-joint.  These  all  depend  on  some  altered  condition 
of  the  spinal  nerves,  and  their  recognition  saves  much  valu- 
able time  to  the  patient.  These  are  the  cases  that  "  go  the 
rounds,"  see  all  physicians,  and  are  finally  cured  either  by 
heroic  treatment  or  by  the  magic  touch. 

It  is  quite  true  that  neurological  science  is  furnishing 
much  that  is  of  value  to  us  in  the  study  of  joint  diseases, 
and  in  no  affection  is  the  connection  between  the  two 
specialties  more  marked  than  in  neuroses. 

I  have  had  the  courage  to  introduce  a  chapter  on  Rheu- 


20  DISEASES  OF  THE  HIP. 

matism  among  the  diseases  of  the  hip.  All  of  us  are 
taught  to  look  with  a  deep  sense  of  pity  on  a  man  who 
calls  a  "  hip-disease"  "  rheumatism,"  and  we  begin  to  think 
that  this  is  one  of  the  errors  of  the  dark  ages.  My  sense 
of  pity  is  not  so  acute  as  it  formerly  was,  and  I  have 
reached  the  conclusion  from  cases  in  actual  practice  that 
subacute  and  chronic  rheumatism,  both  of  the  muscular 
and  the  arthritic  varieties,  do  exist  in  the  monarticular 
form  in  children.  I  have  incorporated  several  cases  that 
seem  to  me  conclusive.  In  districts  where  damp  weather 
prevails  and  where  malaria  abounds  there  are  many  cases  of 
this  nature;  and  while  some  clinical  lecturer  may  occasion- 
ally find  a  child  at  his  clinic  in  whom  rheumatism  has  been 
diagnosticated  where  a  true  bone  disease  exists,  there  are 
many  more  in  whom  such  a  diagnosis  has  been  made  that 
do  not  come  to  the  clinic.  Still,  this  is  a  not  uncommon 
error,  and  a  chapter  on  the  subject  will  serve  to  bring  out 
the  points  in  diagnosis  all  the  more  sharply. 

On  the  subject  of  chronic  rheumatic  arthritis — themalutn 
coxae  senile  of  some  authors — I  fear  I  have  not  been  suffi- 
ciently explicit.  Many  of  these  cases  I  have  had  an  oppor- 
tunity of  examining,  and  have  made  myself  familiar  with 
their  clinical  history;  but  I  have  not  had  the  treatment  of 
the  same,  because  the  hospital  with  which  I  am  connected 
is  exclusively  for  children.  Still,  from  a  study  of  a  few 
that  I  have  seen  under  treatment  and  reported  in  current 
literature,  I  have  aimed  to  set  forth  principles  in  treatment 
that  I  feel  convinced  will  lead  to  good  results.  These  are 
a  very  unfortunate  class  of  sufferers,  and  the  lesion  once 
being  recognized,  free  passive  motion  of  the  joint  under  an 
anaesthetic  sometimes  affords  decided  relief. 

While  the  term  periarthritis,  as  originally  employed,  desig- 
nated a  subacute  or  chronic  lesion  limited  to  the  fibrous 
structure  in  close  proximity  to  the  joint,  I  have  found  it  very 
useful  to  designate  by  this  term  an  acute  cellulitis  a  little 
more  remote  from  the  joint,  yet  by  contiguity  often  involving 
structures  more  closely  related.  This  periarticular  cellu- 
litis, then,  I  have  been  in  the  habit  of  calling  a  coxo-femo- 
ral  periarthritis.  The  name  seems  to  me  a  good  one,  and 
I  cannot  at  present  recall  the  name  of  the  author  to  whom 
we  are  indebted  for  its  introduction  into  our  nosology.  It  is 
nearly  always  acute,  and  nearly  always  terminates  without 
seriously  impairing  the  joint  functions.  It  is  a  comparatively 


THE   INTRODUCTION.  21 

trivial  disease,  with  very  alarming  signs  and  symptoms; 
hence  the  importance  of  recognizing  the  lesion,  and  dis- 
tinguishing it  from  the  chronic  bone  disease  in  the  neigh- 
borhood of  the  hip.  Its  early  recognition  is  also  important, 
in  view  of  advantage  to  be  gained  by  early  incision  of  puru- 
lent areas.  These  abscesses  in  children  not  suffering  from 
any  malnutrition  are  harmless;  but,  occurring  in  patients 
whose  assimilative  powers  are  poor,  whose  constitution  is 
depraved,  the  effects  at  times  are  very  disastrous.  In  my 
chapter  I  have  sought  to  fully  illustrate  this  condition  by 
typical  cases  taken  from  our  hospital  records.  If  I  have 
not  insisted  strongly  enough  in  the  context  on  the  impor- 
tance of  distinguishing  these  areas  of  infiltration  from 
similar  conditions  occurring  in  connection  with  the  second 
stage  of  a  chronic  articular  ostitis  very  insidious  in  its 
approach,  I  take  the  present  opportunity  of  calling  atten- 
tion to  the  subject,  and  know  of  no  better  way  of  avoiding 
error  than  in  the  cultivation  of  a  habit  of  securing  reliable 
histories.  One  essential  point  in  the  history  at  all  times  is 
the  existence  or  not  of  lameness  long  prior  to  the  develop- 
ment of  the  acute  symptoms.  Another  point  in  connection 
with  this  is  the  presence  of  the  infiltration. 

The  subject  of  Bursitis  of  the  Hip  has  not  heretofore,  so 
far  as  my  reading  goes,  been  honored  with  a  special  chapter 
in  works  on  joint  disease.  The  impetus  given  to  the  study  of 
the  bursae  by  Mr.  Henry  Morris  has  enabled  us  to  more  easily 
recognize  these  simple  lesions,  and  the  separation  of  the  same 
from  bone  diseases  renders  still  simpler  the  study  of  the 
more  serious  affection.  If  one  meets  with  a  case  of  primary 
bursitis  and  has  an  opportunity  of  observing  it  throughout 
its  course,  he  will  be  less  disposed  to  call  every  swelling 
bursitis,  that  occurs  in  the  vicinity  of  the  bursa.  The 
whole  subject  is  to  me  an  extremely  interesting  one,  and 
the  few  cases  I  have  had  under  treatment  seemed  worthy 
of  collection  into  a  separate  chapter.  The  time  may  come, 
when  their  nature  is  the  more  fully  understood,  and  their 
exact  relationship  to  surrounding  structuresthe  better  appre- 
ciated, that  antiseptic  surgery  will  enable  us  to  effect  more 
speedy  cures,  and  thus  add  another  laurel  to  the  wreath 
that  must  adorn  the  brow  of  the  immortal  Lister.  From 
the  experience  I  have  had  I  cannot  help  thinking  that  a  few 
cases  at  least  are  subjected  to  mechanical  treatment  by  the 
indiscriminate  use  of  such  means  in  the  hands  of  those 


22  DISEASES   OF  THE   HIP. 

who  belittle  diagnosis  at  the  expense  of  joint  therapeu- 
tics. 

Another  subject  equally  important  with  that  of  bursitis 
is  acute  primary  coxo-femoral  Synovitis.  A  case  of  this 
occurring  in  one's  practice,  and  closely  studied,  will  shake 
one's  faith  in  the  current  pathology  of  joint  disease.  It  will 
show  that  hip-disease,  as  popularly  understood,  does  not,  as 
a  rule,  begin  in  the  synovial  membrane.  My  hospital  facil- 
ities have  enabled  me  to  make  a  somewhat  extended  study 
of  this  disease,  and  hence  I  recognize  the  importance  of 
differentiating  the  lesion  from  the  bone  lesions — the  start- 
ing-point, as  I  believe,  of  the  vast  majority  of  cases  of 
"hip-disease." 

In  the  chapter,  however,  devoted  to  this  subject  I  have 
endeavored  to  avoid  bias,  and  to  recognize  the  fact  that 
"  hip-disease"  does  sometimes  begin  in  this  way.  The  sub- 
ject, therefore,  has  been  elaborated  as  fully  as  my  time 
would  permit,  and  I  trust  it  is  made  sufficiently  clear  to  fur- 
nish the  reader  with  some  suggestions,  at  least,  that  will 
enable  him  to  pursue  the  study  in  a  satisfactory  manner. 
It  will  be  seen  that  I  have  not  fully  developed  the  subject 
of  chronic  synovitis  of  the  hip,  and  my  apology  for  not  de- 
voting more  attention  to  this  lesion  is,  that  I  believe  when 
such  a  lesion  does  occur  its  tendency  is  to  involve  the 
deeper  tissues  and  make  a  genuine  hip-disease.  Still  there 
are,  I  fancy,  cases  of  chronic  synovitis  occurring  in  adult 
life  where  the  bone  does  not  become  involved.  We  are 
prone  to  regard  such  as  rheumatism,  and,  foraH  practical 
purposes,  the  classification  is  not  objectionable. 

Chapter  IX.,  is  devoted  to  a  subject  that  is  growing  in  im- 
portance, thanks  to  the  researches  of  pathology.  We  are 
indebted  to  English  observers  for  the  light  that  has  been 
thrown  upon  Epiphysitis,  and  the  recent  meeting  of  the 
British  Medical  Association  brought  out  several  papers  on 
this  subject  that  must  prove  of  great  value  in  the  study  of 
joint  diseases.  Many  cases  that  we  have  been  in  the  habit 
of  classing  among  congenital  luxation  and  among  trau- 
matic separation  of  the  epiphysis  we  can  now  look  upon 
as  due  to  acute  inflammatory  diseases  occurring  in  very 
early  life. 

Mr.  Thomas  Smith,  in  the  St.  Bartholomew  Hospital  Re- 
ports of  1874,  describes  quite  minutely  this  affection  as 
"  acute  arthritis  of  infants,"  and  I  find  that  my  own  cases 


THE  INTRODUCTION.  23 

correspond  very  closely  with  those  he  has  reported.  It  is 
to  him  we  owe  our  knowledge  of  the  pathological  processes. 
It  is  but  fair,  however,  to  my  own  chapter  to  say  that  I 
was  not  familiar  with  this  contribution  to  our  literature 
when  I  recorded  my  own  cases.  As  remarked  in  that  chap- 
ter, I  was  at  a  loss  for  a  long  while  how  to  classify  the  ma- 
terial, and  in  my  intercourse  with  my  orthopedic  confreres 
in  this  city  I  found  very  little  to  help  me  in  my  study. 
The  cases  seemed  to  have  drifted  into  my  hands,  and  I  knew 
of  only  one  that  had  come  under  the  observation  of  another 
practitioner  in  this  specialty,  and  that  practitioner  was  Dr 
A.  B.  Judson. 

In  the  same  hospital  reports — the  fifteenth  volume — Mr. 
Eve  deals  with  the  pathological  aspects  of  necrosis  at  the 
extremity  of  the  diaphysis  and  in  the  epiphysis  of  growing 
bones,  and  contributes  a  valuable  addition  to  the  subject  of 
epiphysitis.  Mr.  W.  Morrant  Baker,  surgeon  to  St.  Bar- 
tholomew's, at  the  last  meeting  of  the  British  Medical  As- 
sociation, threw  out  some  valuable  suggestions  as  to  treat- 
ment in  a  paper  on  "epiphysal  necrosis  and  its  consequences.' 
A  reference  to  these  papers  from  that  time-honored  hos- 
pital will  supplement  the  chapter  I  have  here  introduced. 

The  second  part  of  this  chapter  deals,  in  a  negative 
way,  with  diastasis  of  traumatic  origin,  and  I  much  regret 
my  lack  of  clinical  material  to  make  this  portion  more  at- 
tractive. Its  close  relationship,  however,  with  acute  epiphy- 
sitis and  with  diastasis,  the  result  of  slow  pathological 
changes  in  chronic  diaphyso-epiphysitis,  is  brought  out  by 
illustrative  cases,  and  this  relationship  may  enable  us  to  bet- 
ter recognize  those  of  traumatic  origin.  In  this  way  then,  I 
fain  would  believe,  the  chapter  will  prove  a  contribution,  a'; 
least,  to  the  diagnosis  of  chronic  articular  ostitis. 

Periostitis  of  the  hip  and  malignant  diseases  are  consid- 
ered in  Chapter  X.  This  brings  us  nearer  to  the  lesion  of 
the  hard  parts,  and  introduces  us  to  diseases  that  are 
often  of  grave  import.  This  is  particularly  true  of  malig- 
nant diseases.  In  selecting  a  caption  for  this  chapter  the 
term  periarticular  periostitis  occurred  to  me;  but,  on  reflec- 
tion, the  qualifying  adjective  seemed  to  be  entirely  super- 
fluous. A  periostitis  is  naturally  periarticular,  and  the  asso- 
ciation of  this  term  with  the  joint  locates  the  lesion  at  the 
hip.  I  have  dealt,  however,  with  the  disease  as  a  primary 
lesion;  and  while  there  are  cases  wherein  pus  dissects  up 


24  DISEASES  OF  THE  HIP. 

the  periosteum  and  where  a  peripheral  ostitis  induces  a  peri- 
ostitis, these  cases  would  add  nothing  to  the  subject  from  a 
therapeutic  standpoint.  These  conditions  are  found  occa- 
sionally associated  with  ostitis  beginning  in  the  centres  of 
ossification,  the  inflammation  extending  to  the  periphery. 
Again,  we  are  all  familiar  with  periosteal  lesions  of  the 
femur,  induced  by  spinal  abscesses,  but  these  are  inter- 
esting only  in  a  differential  way.  If  I  have  not  made 
myself  sufficiently  clear  in  tracing  the  development  of  an 
articular  ostitis  from  a  periostitis,  it  has  been  because  of 
the  lack  of  pathological  data.  I  want  it  understood,  how- 
ever, that  I  am  not  an  unbeliever  in  this  mode  of  production 
of  a  "hip-disease."  In  the  second  part  of  this  chapter  the 
only  malignant  disease  that  I  have  attempted  to  elaborate 
is  the  round-celled  periosteal  sarcoma.  The  other  forms  of 
malignant  diseases  are  very  infrequent,  and  indeed  rarely 
ever  occur  in  childhood.  Once  recognized  the  question  of 
therapeutics  admits  of  little  discussion.  This  belongs 
more  properly  to  the  works  on  general  surgery,  and  to  such 
those  interested  in  this  subject  can  refer. 

The  larger  part  of  this  work  is  devoted  to  chronic  articu- 
lar ostitis,  and  this  disease  certainly  demands  a  large  space. 
It  will  be  seen  in  the  caption  of  the  chapter  on  pathology 
that  I  make  this  name  synonymous  with  morbus  coxarius, 
morbus  coxae,  hip-joint  disease,  etc.  The  views  as  to  the 
pathology  are  undergoing  radical  changes  now,  and  we  are 
gradually  coming  to  recognize  a  central  ostitis  as  the  lesion, 
which  will  explain  the  more  important  features  of  the  dis- 
ease in  question.  Once  a  clear  idea  of  the  pathogeny  and 
the  pathological  changes  is  had  the  indications  to  be  met 
can  be  more  readily  appreciated,  and  the  case  be  better 
conducted  to  a  successful  issue.  I  have  purposely  devoted 
considerable  space  to  the  pathology,  having  learned  to  ap- 
preciate its  value  in  all  joint-diseases. 

Concerning  the  etiology  much  has  been  said  in  a  clini- 
cal way,  although  a  little  statistical  work  has  been  inter- 
spersed. I  have  not  collected  the  number  of  cases  of 
disease  affecting  both  joints  and  those  affecting  the  spine 
as  well.  These  would  be  interesting  from  an  etiological 
point  of  view,  but  they  scarcely  merit,  it  seems  to  me,  a 
distinct  chapter,  or  even  a  portion  of  a  chapter. 

For  the  benefit  of  those  who  believe  that  double  "hip- 
disease"  is  an  extremely  rare  affection,  I  would  say  that  it 


THE  INTRODUCTION.  2$ 

occurs  with  more  frequency  than  one  would  imagine.  I  have 
seen  quite  a  number  of  patients  examined  and  treated,  even 
for  bone  disease  affecting  one  hip,  while  the  same  lesion  in  the 
other  hip  would  be  entirely  overlooked,  so  insignificant  did 
the  signs  appear  by  comparison.  I  have  also  seen  cases  with 
the  monarticular  form  develop  the  bilateral  form  several 
months  or  a  year  or  two  later.  I  have  in  mind  now  two 
cases  that  I  saw  some  two  and  a  half  years  ago,  and  I  am 
sure  that  the  disease  existed  only  on  one  side.  When  I  saw 
them  again — one  eight  months  and  one  two  years  afterward 
— they  were  wearing  hip  splints  for  undoubted  disease  on 
both  sides. 

I  believe  that  some  of  us  at  least  are  deceived  in  this  way: 
We  examine  a  hip,  and  find  signs  of  the  first  stage;  we  also 
find  some  obscure  signs  about  the  other  hip,  and  delude 
ourselves  into  believing  these  to  be  sympathetic.  I  am 
growing  very  skeptical  concerning  sympathetic  hips.  Still 
I  am  free  to  say  that  I  have  never  committed  myself  strongly 
to  that  belief.  It  has  become  a  habit  with  me  to  place  implicit 
reliance  on  certain  signs  found  about  a  hip,  even  if  all  the 
joints  are  the  seat  of  disease. 

I  have  not  devoted  any  space  in  the  body  of  the  work  to 
a  consideration  of  hip  lesions  associated  with  similar  lesions 
in  other  joints  and  in  the  spine.  I  have  notes  of  a  number 
of  cases  of  spinal  caries  with  bone  lesions  of  the  hip;  in- 
deed it  is  sometimes  difficult  to  tell  which  was  the  primary 
disease.  I  have  under  treatment  at  present  a  girl  aged  five 
years  who  has  lumbar  caries,  ostitis  of  both  hips,  and  ostitis 
of  the  carpal  bones.  These  are  interesting  facts  to  know,  in 
order  that  one  may  not  set  aside  signs  of  diagnostic  value 
because  other  joints  are  involved.  All  such  cases  would 
have  been  mentioned  had  I  undertaken  to  write  a  statistical 
work.  I  have  avoided  statistics  as  far  as  was  practicable  in 
order  to  make  the  book  more  readable. 

The  questions  of  trauma  and  struma  have  not  been  placed 
in  antithesis,  because  I  do  not  believe  such  a  relationship 
should  exist.  In  describing  the  etiology  I  have  taken  it  for 
granted  as  settled  that  the  bulk  of  the  profession  believe  in 
a  strumous  diathesis;  if  not  hereditary,  then  acquired.  Given 
then  this  strumous  diathesis,  this  cachexia,  this  evidence 
of  malnutrition,  it  is  very  easy  fora  concussion  to  induce  a 
hyperaemia  of  the  centres  of  development,  which  hyper- 
aemia  under  certain  conditions  will  result  in  inflammation. 


26  DISEASES  OF  THE  HIP. 

It  is  also  well  established  that  these  foci  of  disease  can 
originate  without  even  a  fall  as  exciting  cause.  I  am 
willing,  then,  to  admit  that  falls  which  induce  a  concussion 
in  young  children  or  sprain  or  contusion  in  older  children 
are  the  exciting  cause  in  a  large  number  of  cases;  but  I  am 
not  willing  to  admit  that  the  individuals  thus  affected  are 
free  of  a  diathesis  which  we  call  strumous.  The  cases  and  the 
other  facts  all  go  to  prove  the  above  two  propositions,  and 
1  am  sure  that  all  unbiased  observers  will  arrive  at  the 
same  or  similar  conclusions. 

I  have  deemed  it  necessary  to  fully  illustrate  the  clinical 
history,  for  the  reason  that  many  good  surgeons  practising 
this  specialty  even  seem  to  be  at  a  loss  to  understand  the 
nature  of  this  disease.  They  seem  to  think  that  it  gets  well 
in  six  months  or  a  year;  that  the  subsidence  of  acute  symp- 
toms means  a  cure;  that  an  exacerbation  yielding  to  treat- 
ment justifies  them  in  applauding  the  particular  means  em- 
ployed. So  that  I  have  endeavored  to  make  this  chapter 
especially  full.  The  material  at  hand  encourages  me  to 
Delieve  that  I  can  certainly  do  justice  to  the  clinical  history. 

The  subject  of  diagnosis  too  is  dealt  with  at  some  length, 
the  different  stages  being  accorded  special  parts  in  the  chap- 
ter; and,  in  view  of  the  importance  of  a  clear  understanding, 
especially  in  the  early  stage,  no  apology  is  offered. 

In  discussing  treatment  I  have  attempted  to  explain  what 
is  meant  by  the  expectant  treatment,  giving  cases  by  way  of 
illustration.  It  does  seem  though  that  the  time  will  come 
when  all  mechanical  treatment  will  be  considered  as  expec- 
tant. 

Extreme  views  may  have  found  a  place  in  this  portion  of 
the  volume,  but  they  are  views  based  on  solid  experience 
and  if  they  are  not  accepted  I  can  well  afford  to  let  them 
take  their  course  as  facts.  The  physiological  treatment 
is  given  a  place.  I  feel  entitled  to  speak  at  some  length 
on  this  method,  for  I  have  had  a  large  proportion  of  my 
out  patients  on  crutches  and  a  high  shoe.  The  idea  of 
leaving  the  hip  unprotected  save  as  the  reflex  spasm  in 
the  muscles  protects  the  hip  is  peculiar  to  Dr.  Hutchison, 
and  there  are  cases  occasionally  met  with  that  seem  to  do 
well  with  the  shoe  and  crutches  alone. 

In  this  country  we  are  not  disposed  to  accept  the  treat- 
ment advocated  by  Mr.  Hugh  Owen  Thomas  of  Liverpool, 
but  it  certainly  seems  to  possess  advantages  over  the 


THE  INTRODUCTION.  2? 

strictly  physiological.  The  hip  is  well  fixed,  it  would  seem; 
though  recent  writers  who  have  attempted  to  carry  out  Mr. 
Thomas's  instructions  are  very  loath  to  bear  testimony  to  the 
facility  of  application  of  the  apparatus.  The  weight  of  the 
steel,  the  disposition  to  turn,  and  various  other  minor 
points  of  detail,  so  simple  to  the  inventor,  are  not  by  any 
means  simple  to  the  practitioner.  The  true  value  of  the 
treatment  is  discussed  at  length. 

Concerning  the  subject  of  traction  and  extension  appara- 
tus, there  is  much  that  is  as  yet  unsettled.  The  object  is, 
I  take  it,  to  bring  about  ankylosis  in  the  best  position. 
This  is  what  many  of  the  splints  do,  and  it  is  immaterial 
what  is  claimed  for  them.  The  correction  of  deformity  by 
screws  is  condemned  by  some  who  employ  apparatus.  The 
limb  is  left  to  take  care  of  itself. 

If  I  have  not  given  all  the  forms  in  common  use  it  is 
because  of  my  limited  time  in  which  to  collect.  Many 
splints  I  know  are  pictured  in  catalogues,  but  are  no  longer 
in  use. 

The  chapter  on  operative  treatment  has  been  devoted  to 
drilling  in  the  early  stage,  to  excision  in  the  latter  stages, 
and  to  osteotomy  for  correction  of  deformity.  There  are 
many  cases  on  record  of  what  seem  to  be  good  results,  but 
enough  time  has  not  elapsed  to  make  them  of  any  special 
value  for  statistical  purposes. 

In  concluding  then  this  chapter  let  me  insist  again  on 
the  importance  of  a  thorough  examination  in  every  case. 
The  object,  in  the  first  place,  should  be  to  have  a  proper 
classification,  and  to  bear  this  in  mind  when  examining  a 
patient.  There  are  certain  signs  that  can  be  discovered 
only  when  the  patient  is  divested  of  all  clothing.  The 
tape-measure  is  an  essential — the  goniometer  is  useful 
but  above  all  things  a  practised  eye  and  an  unbiased  mind 
are  indispensable.  In  classifying  cases  for  statistical  pur- 
poses a  few  years  ago  the  committee  on  surgical  procedure 
in  the  Therapeutical  Society  met  with  many  difficulties  in 
the  way  of  harmony.  I  drew  up  a  schedule  which  was 
supplemented  by  several  specialists,  and  the  form  we  finally 
accepted  is  submitted  for  further  use. 

I  would  premise  by  stating  that  some  confusion  yet  exists 
concerning  the  measurement  of  angles.  I  have  advised  with 
a  number  of  orthopedists,  and  I  find  that  in  recording 
angles  the  supplement  of  a  right  angle  is  used  when  the 


28  DISEASES  OF  THE  HIP. 

deformity  is  less  than  90°.  The  starting-point  is  taken 
from  the  direction  of  the  head,  and  the  limb  is  moved  over 
the  articulation  with  the  plane  of  the  body  as  the  base.  So 
that  when  the  limb  is  on  a  line  with  the  body  we  have 
180°,  and  not  o  as  some  estimate  angles.  It  would  be 
better  I  think,  for  the  sake  of  unanimity  in  recording  cases, 
to  adopt  this  method. 

The  following  is  the  schedule  in  conformity  with  which 
cases  may  be  reported  for  the  use  of  statisticians : 

i.  Sex.  2.  Age  when  disease  developed.  3.  Side  affected. 
4.  Date  of  first  symptoms.  5.  Symptoms  at  invasion.  6. 
Apparent  seat  of  initial  lesion  :  bone,  including  periosteum  ;  or, 
soft  parts,  including  synovial  membrane.  7.  Exciting  cause  as 
stated  by  patient.  8.  Interval  between  this  and  first  symp- 
tom. 9.  Date  of  first  examination.  10.  Detail  the  signs 
found  ;  as  shortening,  atrophy,  angle  of  deformity,  limitation  of 
movements,  usefulness  of  limb,  abscess,  pain,  etc.  n.  Previous 
treatment:  each  method,  and  duration  of  same.  12.  Sub- 
sequent treatment,  with  duration  of  same.  13.  When  did 
the  opening  take  place  leading  to  carious  bone  ?  14.  When 
did  the  sinus  or  sinuses  close  permanently?  15.  Extent  of 
carious  process.  16.  Condition  when  treatment  suspended, 
with  date,  (a)  Shortening :  real,  practical.  (£)  Atrophy. 
(c]  Mobility  in  angles:  flexion,  extension,  abduction,  adduction, 
rotation,  (d]  Position  of  limb,  (e)  usefulness  of  limb. 
We  have  aimed  to  make  our  examinations  in  conformity 
with  these  questions,  and  are  accumulating  some  valuable 
material. 

To  get  the  length  of  a  limb  there  are  several  points  from 
which  to  measure.  The  anterior-superior  spinous  process 
is  the  more  usual  point.  This  gives,  if  the  limbs  are  sym- 
metrically placed,  the  real  shortening.  From  the  umbilicus 
the  practical  shortening  is  obtained,  also  from  the 
perineum.  To  get  the  shortening  from  bone  atrophy  or 
arrest  of  development  measure  from  the  tip  of  the  tro- 
chanter. 

The  position  of  the  trochanter  and  its  relative  distance 
from  the  basin  of  the  acetabulum  are  certainly  important 
points  to  note,  and  Nelaton's  line  enables  one  to  decide 
whether  the  tip  of  trochanter  is  above  or  below  the  normal 
position. 

In  concluding  this  introductory  chapter  let  me  insist 
upon  the  necessity  of  employing  all  the  means  at  our  dis- 


THE  INTRODUCTION.  2Q 

posal  for  thorough  examination.  The  family  history,  the 
personal  history,  the  sequelae  of  the  exanthemata,  the  sud- 
denness of  invasion  or  the  slow  insidious  invasion — all 
these  should  be  clearly  understood  to  make  physical  signs 
of  value  in  diagnosis  and  in  prognosis. 


CHAPTER  II. 
THE  ANATOMY  OF  THE  HIP. 

In  general  terms  the  word  hip  is  employed  to  designate 
not  only  the  immediate  structure  entering  into  the  forma- 
tion of  the  joint,  but  the  structures,  both  hard  and  soft, 
which  contribute  to  the  functions  of  the  same.  In  popular 
parlance,  the  integumentary  coverings  go  to  complete  the 
full  group  of  tissues  embodied  in  the  term  hip.  If  one 
bruises  the  skin  in  the  neighborhood  of  the  trochanters  the 
hip  is  bruised;  if  a  furuncle  form  in  this  neighborhood  the 
boil  is  on  the  hip.  Neither  does  the  profession  nor  the 
laity  draw  a  sharp  distinction  between  the  different  struc- 
tures in  and  about  the  joint  when  casually  discussing  this 
subject.  Webster  defines  the  hip  as  "  the  projecting  part 
of  the  trunk  of  an  animal  formed  by  the  lateral  parts  of  the 
pelvis  and  the  hip-joint  with  the  flesh  covering  them;  the 
haunch."  It  is  an  Anglo-Saxon  word. 

The  term,  then,  hip-disease  is  a  general  one,  and  while 
many  authorities  endeavor  to  have  it  restricted  to  lesions 
primarily  involving  the  immediate  joint  structures  it  is 
really  applicable  to  lesions  of  any  part  of  the  hip.  It  is  in 
this  way  that  confusion  arises.  When  one  says  he  has 
cured  a  case  of  hip-disease  you  do  not  know  just  what 
meaning  he  intends  to  convey,  and  if  you  demand  an  ana- 
tomical diagnosis  he  will  very  often  find  it  difficult  to  tell 
you  just  what  he  does  mean.  It  is,  therefore,  very  neces- 
sary to  a  proper  understanding  of  the  diseases  in  and  about 
this  joint  that  one  bear  in  mind  the  various  anatomical 
structures  entering  into  its  formation.  It  is  well,  too,  to 
bear  in  mind  that  inflammatory  diseases  and  neoplasms 
attacking  particular  structures  in  this  vicinity  deal  with 
them  just  about  as  they  deal  with  like  structures  in  other 
vicinities.  The  early  recognition  of  the  tissues  involved 
and  the  nature  of  the  morbid  process  will  naturally  suggest 
appropriate  efforts  at  least  in  preventing  an  extension  of 
the  disease  to  other  parts,  the  involvement  of  which  may 
or  may  not  be  of  vital  importance. 


THE  ANATOMY  OF  THE  HIP.  31 

Looking,  then,  at  a  naturally  formed  hip  one  must  learn 
by  observation  the  contour  of  the  parts,  the  appearance  of 
the  skin,  the  folds  and  dimples  into  which  it  is  thrown, 
while  the  subject  assumes  different  attitudes.  Art  students 
naturally  become  familiar  with  surface  anatomy,  and  medi- 
cal men  should  by  all  means  study  the  normal  appearance, 
not  only  of  the  hip  but  of  all  the  joints.  Indeed,  surface 
anatomy  plays  a  very  important  part  in  orthopedic  surgery. 

The  prominence  of  the  nates,  of  course,  stands  out  most 
conspicuously  as  the  erect  position  is  assumed;  the  fulness 
or  the  flabbiness  indicating  health  or  the  reverse.  In  the 
normal  state  we  must  find  absolute  symmetry  in  the  pro- 
minences and  the  depressions.  The  eye  then  takes  in  the 
gluteal  fold,  which  must  not  deflect  to  one  or  the  other 
side;  the  supra-trochanteric  dimples,  or  depressions,  which 
vary  in  depth  and  area  according  to  the  leanness  or  obesity 
of  the  subject,  preserving,  however,  in  any  instance,  a  sym- 
metrical appearance;  the  gluteo-femoral  folds,  marked  by 
fissures  or  creases,  indicating  the  junction  posteriorly  of  the 
thigh  with  the  trunk.  These  creases  vary,  too,  according 
to  the  muscular  or  adipose  development  of  the  individual. 
As  a  rule  the  fissure  is  a  bifurcated  one,  the  upper  curvilin- 
ear being  the  longer,  and  extending  from  the  perineum 
to  the  junction  of  the  posterior  with  the  outer  surface  of 
the  thigh,  while  the  lower,  nearly  straight,  being  the 
shorter  by  one  half,  and  leaving  the  upper  about  an  inch 
from  its  femoral  extremity,  to  extend  an  inch  or  two 
diagonally  down  the  posterior  aspect  of  the  thigh.  Often, 
however,  we  find  a  third  division  or  fissure  much  shorter, 
and  taking  a  course  nearly  vertical  from  the  curvilinear 
above.  We  remember,  too,  that  the  law  of  symmetry  must 
be  recognized  even  in  these  fissures.  Indeed,  one  cannot 
but  help  admire  the  symmetrical  arrangement  of  the  lines 
and  prominences  so  exquisitely  drawn  by  the  hand  of  Nature 
in  a  pair  of  hips  free  from  disease  or  deformity. 

One  must  not  rest  content  with  studying  the  parts 
already  mentioned,  but  the  eye  will  take  in  at  a  compara- 
tive glance  the  position  of  the  trochanteric  prominences — 
the  sacral  region,  the  ilio-costal  spaces,  and  their  relation- 
ship to  the  crista  ilii,  the  size  of  the  thighs  in  the  upper 
third  and,  indeed,  all  the  regions  immediately  connected 
with  the  hip.  Soon  one  learns  to  observe  all  this  at  a 
glance,  and  easily  detects  any  departure,  however  slight, 
from  the  law  of  symmetry. 


32  DISEASES  OF  THE  HIP. 

To  look  through  the  integument  and  recognize  the  muscles 
and  fascia  and  adipose  tissue  immediately  under-lying, 
another  step  in  anatomy- must  be  taken.  The  prominence 
of  the  nates  we  know  is  produced  by  an  accumulation  of 
fat  lying  over  the  gluteal  muscles. 

It  is  by  far  the  better  plan  to  give  the  muscles  which  act 
upon  the  hip-joint  a  classification  according  to  function, 
and  it  shall  be  my  aim  to  enter  as  little  as  possible  into 
anatomical  details. 

THE  FLEXORS. — There  are  two  sets  ;  one  whose  function 
is  pure  flexion,  and  another  whose  function  is  principally 
accessory  to  the  first.  The  former  are  the  psoas  and  the 
iliacus,  practically  forming  a  single  muscle.  Their  attach- 
ments are  extensive,  and  hence  their  importance.  If  disease 
involve  the  bodies  of  the  lower  vertebrae  the  psoas  is 
involved,  and  if  the  ilium  the  sacrum  or  the  capsule  of  the 
joint  is  implicated  the  iliacus  is  excited  often  into  undue 
action.  Both  are  inserted  at  and  below  the  small  trochanter. 
I  have  purposely  omitted  the  psoas  parvus  because  it  has 
no  action  on  the  hip. 

The  latter  group  of  muscles  which  assist  in  flexion  under 
certain  circumstances  are;  the  pectineus,  the  sartorius,  and 
the  rectus.  The  latter  two  can  act  only  when  their  action 
on  the  leg  is  completed  or  prevented.  The  vastus  externus 
is  thought  by  some  anatomists  to  assist  in  flexing  the 
thigh  through  its  attachment  to  the  rectus,  and  the  obtura- 
tor externus  is  occasionally  a  decided  flexor.  This  is 
illustrated  when  you  cross  one  thigh  over  the  other. 

The  flexor  muscles  all  arise  within,  or  along  the  margins 
of,  the  pelvis,  the  psoas  alone  excepted. 

THE  EXTENSORS. — The  three  glutei,  and  these  are  as- 
sisted by  the  obturator  internus  and  the  hamstring  mus- 
cles, the  latter  acting  when  they  have  completed  the 
flexion  of  the  leg,  or  are  prevented  from  so  doing.  Their 
action  can,  however,  have  little  to  do  with  disease  at  the 
hip,  since  they  influence  both  joints  simultaneonsly,  as  in 
the  first  act  of  rising  from  a  seat. 

The  extensors  arise  from  the  pelvic  bones  posteriorly — 
one,  the  obturator  internus  taking  the  greater  portion  of  its 
origin  from  the  inner  surface  of  the  posterior  wall. 

THE  ADDUCTORS — These  pass  between  the  os  innominatum 
and  the  femur,  and  are  the  long,  short,  and  great  adductors, 
assisted  by  the  pectineus  and  the  graciis,  and  occasionally 
by  the  gluteus  maximus,  the  obturator  externus  and  the 


THE  ANATOMY  OF  THE  HIP.  33 

quadratus  femoris.  If  the  limb  be  extended  the  gluteus 
assists  in  adduction,  if  flexed  the  external  obturator  assists, 
and  if  extreme  outward  rotation  is  completed  or'prevented, 
then  the  quadratus  acts  as  an  adductor. 

THE  ABDUCTORS.  —  The  muscles  which  support  the  pelvis 
on  one  thigh  —  the  gluteus  medius  and  gluteus  minimus 
are  strong  abductors,  and  their  most  powerful  action  is 
displayed  when  one  limb  becomes  the  basis  of  support. 
The  gluteus  maximus,  with  its  upper  fibres  and  the  tensor 
vagina  femoris  are  auxiliary  to  the  above  act.  The  sar- 
torius  abducts  while  flexing  both  hip  and  knee. 

THE  INWARD  ROTATORS.  —  The  tensor  vagina  femoris 
and  the  anterior  portions  of  the  gluteus  medius  and  gluteus 
minimus  are  the  muscles  here  employed. 

THE  OUTWARD  ROTATORS.  —  These  muscles  occupy  places 
on  both  sides  of  the  joint,  and  in  front  we  have  the  psoas 
and  iliacus  —  the  chief  flexors.  On  the  inner  aspect  the  pec- 
tineus  and  the  three  adductors;  on  the  inferior  and  posterior 
aspect  the  obturator  externus.  Posteriorly  are  the  quad- 
ratus femoris,  the  gemelli,  the  obturator  internus,  the 
pyriformis,  and  the  posterior  portion  of  the  gluteus  minimus 
and  gluteus  medius.  These  are  all  assisted  by  the  gluteus 
maximus.  When  the  knee  is  extended  the  biceps  femoris 
may  serve  as  an  outward  rotator. 

It  will  be  observed  that  the  muscles  whose  function  it  is 
to  execute  the  angular  movements  of  the  thigh,  act  also  as 
outward  rotators,  and  this  double  function  gives  a  greater 
range  of  motion  to  the  thigh,  i.e.,  if  one  of  the  functions  of 
a  group  of  muscles  is  rendered  unnecessary  the  whole  force 
can  be  directed  toward  the  other.  Abduction,  however,  is 
an  exception. 

To  sum  up,  then,  the  muscles  with  their  functions  we 
have 

FLEXORS. 


{Pectineus. 
Obturator  Externus 
Vastus  Externus. 
Sartorius. 
Rectus. 

Nerve  supply:  The  psoas  is  supplied  by  anterior  branches 


34  DISEASES   OF  THE  HIP. 

of  the  lumbar  nerves,  and  the  iliacus  by  filaments  from 
the  deep  branches  of  the  anterior  crural. 

The  accessory  obturator — which  is  not  always  present — 
the  deep  muscular  branches  from  the  anterior  crural,  and 
occasionally  the  anterior  branches  from  the  obturator,  sup- 
ply the  pectineus. 

Posterior  branches  of  the  obturator  supply  the  obturator 
externus,  while  the  sartorius  gets  filaments  from  the  mid 
die,  or  internal  cutaneous  nerves,  branches  of  the  anterior- 
crural. 

The  vastus  externus  derives  its  supply  likewise  from  the 
anterior  crural,  and  from  the  branch  going  to  the  muscles 
is  given  off  a  filament  which  is  distributed  to  the  articular 
surfaces  of  the  knee. 

EXTENSORS. 

S  Gluteus  Maximus. 
Gluteus  Medius. 
Gluteus  Minimus. 
{The  long  head  of  the  Biceps. 
Semitendinosus. 
Semimembranosus. 
Obturator  internus. 

Nerve  supply :  The  inferior  gluteal,  a  branch  of  the  small 
sciatic,  is  distributed  liberally  throughout  the  gluteus  maxi- 
mus,  and  an  additional  supply  comes  from  a  branch  of  the 
sacral  plexus. 

The  superior  gluteal  of  the  sacral  plexus  supplies  both 
the  gluteus  medius  and  gluteus  minimus.  The  great  sciatic 
furnishes  muscular  branches  to  the  biceps,  the  semitendi- 
nosus  and  the  Semimembranosus  and  the  sacral  plexus 
similar  branches  to  the  obturator  internus. 

ADDUCTORS. 

(  Adductor  Longus. 
Three  Special.  \  Adductor  Magnus. 

(  Adductor  Brevis. 
f  Pectineus. 
I  Gracilis. 
Five  Accessory.  4  Gluteus  Maximus  (when  limb  is  extended). 

Obturator  Externus  (when  thigh  is  flexed). 
[Quadratus  Femoris. 

Nerve  supply;    The  obturator    nerve  supplies    all    the 


THE  ANATOMY   OF  THE  HIP.  35 

muscles  in  this  group  except  the  quadratus  femoris,  while 
the  adductor  magnus  gets  additional  branches  from  the 
great  sciatic.  The  supply  of  the  pectineus  has  already  been 
given.  The  quadratus  femoris  gets  its  entire  supply  from 
the  sacral  plexus. 

ABDUCTORS. 

One  Special. — Tensor  Vaginae  Femoris. 

(  Gluteus  Maximus. 
Three  Accessory.  \  Gluteus  Medius. 

(  Sartorius. 

Nerve  supply :  The  tensor  vaginae  femoris  derives  its  sup- 
ply from  the  inferior  branch  of  the  superior  gluteal,  one  of 
the  important  divisions  of  the  sacral  plexus.  The  sartorius, 
as  before  mentioned,  gets  filaments  from  the  anterior 
crural,  and  the  glutei  from  the  small  sciatic  and  the  superior 
gluteal  branch  of  the  sacral  plexus. 

OUTWARD  ROTATORS. 

'Quadratus  Femoris. 
Gemellus  Superior. 
c"     CM.    •  /  )  Gemellus  Inferior. 
Six  Spectal.\  Obturator  Internus. 

Obturator  Externus. 
Pyriformis. 
Ilio-psoas. 

The  Three  Adductors. 
Pectineus. 

Nine  Accessory. \  Posterior  Fibres  of  the  Gluteus  Medius. 
Posterior  Fibres  of  the  Gluteus  Minimus. 
Gluteus  Maximus. 
Biceps. 

Nerve  supply:  Branches  from  the  sacral  plexus  supply  all 
the  special  muscles  in  this  group,  with  the  exception  of  the 
obturator  externus,  which  is  supplied,  as  already  stated,  by 
posterior  branches  of  the  obturator. 

The  accessory  group  has  already  been  treated  as  to  the 
nerve  supply  under  their  respective  localities  as  special 
muscles,  and  a  repetition  is  unnecessary. 

INWARD  ROTATORS. 

One  Special. — Tensor  Vaginae  Femoris. 

Two  Accuse         \  Anterior  Fibres  of  the  Gluteus  Medius. 
J.  wo  Accessory.    1  Gluteus  Minimus. 


36  DISEASES  OF  THE  HIP. 

The  nerves  supplying  this  group  have  already  been  given 
as  the  superior  gluteal. 

The  blood  supply  of  the  muscles  which  control  the  action  of 
the  hip  is  from  the  profunda  femoris  chiefly.  This  is  a 
large  branch  of  the  femoral. 

THE  FASCIA  OF  THE  HIP. 

There  is  a  superficial  fascia  of  the  thigh  described  in  the 
works  on  anatomy,  but  as  this  has  no  special  connection 
with  the  diseases  of  the  hip  I  pass  to  a  consideration  of 
the  deep  fascia — the  fascia  lata.  Deep  abscess,  acute  and 
chronic,  is  rendered  particularly  dangerous  by  reason  of  this 
fascia  which  furnishes  a  uniform  investment  for  the  whole  of 
the  upper  third  of  the  thigh,  receiving  fibrous  expansions 
from  the  gluteus  maximus,  the  biceps,  sartorius,  gracilis, 
semi-tendinosus,  and  quadriceps,  while  the  tensor  vaginae 
femoris  is  inserted  between  its  layers.  It  is  attached  above 
to  Poupart's  ligament  and  to  the  crest  of  the  ilium;  behind, 
to  the  margin  of  the  sacrum  and  the  coccyx.  It  is  attached 
to  the  whole  length  of  the  thigh-bone,  from  the  inter- 
trochanteric  line  to  the  widening  of  the  linea  aspera. 

The  numerous  smaller  septa  enclose  individual  muscles 
and  are  attached  to  the  main  fasciae.  The  saphenous  open- 
ing is  simply  a  large  oval  aperture  in  this  tissue,  and 
through  it  abscesses  from  the  deep  structures  often  find 
their  way  to  the  surface. 

In  this  locality  the  fascia  is  divided  into  an  iliac  and  a 
pubic  portion.  The  former  includes  all  that  portion  on  the 
outer  side  of  the  saphenous  opening  being  attached  exter- 
nally to  the  anterior  superior  spine,  to  Poupart's  ligament, 
and  to  the  pectineal  line  in  connection  with  Gimbernat's 
ligament.  It  forms  as  it  passes  down  from  the  spine  to  the 
pubis  the  outer  boundary  of  this  opening.  The  pubic 
portion  lies  on  the  inner  side  of  the  saphenous  opening.  It 
covers  the  surface  of  the  pectineus,  passing  behind  the 
sheath  of  the  femoral  vessels,  being  closely  adherent 
thereto,  and  is  continuous  with  the  sheath  of  the  psoas  and 
iliacus  muscles.  It  is  lost  finally  in  the  capsule  of  the  hip- 
joint. 

THE   BURSJE  ABOUT  THE  HIP. 

The  synovial  bursae  in  this  region  are  nine  in  number, 
and  subserve  an  important  function.  They  consist  of  a  thin 
wall  of  connective  tissue  partially  covered  by  epithelium, 


THE   ANATOMY   OF  THE   HIP. 


37 


and  contain  a  viscid  fluid.  Naturally  they  enhance  the  free- 
dom with  which  muscles  move  over  bony  prominences  and 
tendons.  One  can  readily  see  how  imperfectly  these  muscles 
act  when  their  underlying  bursae  are  not  in  perfect  con- 
dition. 

Figures  i  and  2  I  have  had  copied  from  Morris.    A  large 
bursa  (D,  Fig.  i)  lies  between  the  iliacus  and  the  thin  por- 
tion of  capsular  ligament  di- 
rectly in  front  of  the  joint,  and 
it  often  communicates  with  the 
synovial  cavity.     Its  joint  con- 
nection   makes    it   a   very  im- 
portant element  in  the  patho- 
geny  of  disease  affecting  this 
articulation. 

Between  the  gluteus  medius 
and  the  upper  and  front  por- 
tion of  the  trochanter  major 
there  is  a  small  bursa  (I,  Fig.  i). 
It  extends  quite  a  distance  be- 
tween the  tendon  of  this  muscle 
nad  that  of  the  pyriformis. 
Occasionally  two  bursae  in- 
stead of  one  are  found  ;  one 
between  the  tendon  and  the 
bone  and  the  other  between 
the  tendon  and  the  pyriformis. 

A  bursa  (F,  Fig.  t.)  of  larger 
size  than  the  preceding  lies  be- 
tween the  tendon  of  the  gluteus  FIG.  i.— BURS^E  IN  FRONT  OF  THK  JOINT. 
minimus  and  the  front  of  the  A.  Bursa  between  pectineus  and 
trnrhanter  <;nmprirnp<;  evrfnrl-  femur;  B.  Adductor  brevis;  C.  Pec- 
er>  S  tineus;  D.  The  bursa  between  the  ilio- 

ing  between  this    muscle  at    Its    psoasand  the  capsule  of  the  hip,  often 
in^prtinn  anrl    tVio  vactiic  PYtPr      communicating  with  the  joint;  E.  Ilia- 
_i  Liou  aiiu    Liie  VdbLUb  exier-    cus  ;   p_  Bursa  between  gluteus  mini- 

nus  at  its  attachment. 

Lying  in  front  of  the  gluteUS    bursa    between 

maximus,  and  between  it  and   ~luteus maxiumus and  vastus  extends : 

the    vastus    CXternuS  is  a  bursa    K.  Gluteus  maximus;  L.  Vastus  exter- 

(J,  Fig.  i)  of  larger  size,  over 

which  rides  the  strong  fascia  of  the  buttock  as  it  passes  down 

the  thigh  towards  the  insertion  of  the  first  named  muscle. 

At  the  base  of  the  great  trochanter  is  a  large  multi- 
locular  bursa  (A  and  B,  Fig.  2),  over  which  the  dense  fascia 
and  the  tendon  of  the  gluteus  maximus  play. 


mus  and  trochanter;  G.  Gluteus  mini- 
mus ;    H.    Gluteus  medius;     I.    Small 
;luteus    medius     and 
trochanter;     J.   Small    bursa    between 
•luteus  maxiumus  and  vastus  externus ; 

:.  G 

nus. 


DISEASES  OF  THE  HIP. 


The  remaining  four  bursae  are  at  the  back  of  the  joint 
and  are  arranged  in  the  following  order: 

An   unimportant  bursa  situated   between   the  external 

obturator  and  the  pos- 
terior portion  of  the 
neck  of  the  femur. 

A  large  bursa  be- 
tween the  quadratus 
femoris  and  the  pos- 
terior surface  of  the 
small  trochanter. 

Frequently  an  elon- 
gated bursa  is  found 
between  the  internal 
obturator  and  the 
gemelli  muscles,  and 
capsule  of  the  joint  in 
its  posterior  portion. 

Then  there  are  bur- 
sal  inter-spaces  con- 
taining the  usual  bursal 
fluid,  between  the 
quadratus  femoris  and 
the  obturator  externus, 
and  the  capsule  pos- 


teriorly. 


THE    LIGAMENTS. 


Fig.  2. — BURSJE  AT  THE  BACK  OF  JOINT. 


i.  The  Capsular,  This 

A.  and  B.  Two  small  bursse  between  the  tendon    •     «.!,_         ,T^il, 
•f  fluteus  maximus  and  bone;  C.  Large  bursa  be-    IS  the  enveloping  StrUC- 
•wecn  gluteus  maximus  and  trochanter;  D.  Bursa    £ure    of     the      hip-ioint 
between  obturator  internus  and  capsule  of  hip; 
1.  Bur»a  between  gluteus  medius  and  pyriformis; 
V.  Pyriformis;  G.  Gluteus  minimus;  H.  Gemellus 
•uperior;  I.  Bursa  between  obturator  internus  and 
ischium;    J.    Obturator  internus  cut    across;    K. 
Gtmellui  inferior;  L.  and  M.  Small  bursae  in  con- 
nection with  hamstring  muscles  at  their  origin. 


at- 


,.    ,         , 
WHICH      GCnVCS     ItS 

+0c>Vim<»ntc       frr\m        tVi«» 
lacl 

pelvis       at      a      slightly 

varying  c 

the     acetabulum,    and 

from  the  femur  about  the  junction  of  the  neck  with  the 

shaft. 

*.   The  Cotyloid,  a  fibro-cartilaginous  rim  attached  to  the 

margin  of  the  acetabulum  which  it  thereby  deepens. 

3.  The  Teres,  or   round  ligament,  an  inter-articular  flat 
band  extending  from  the  acetabular  notch,  to  the  dimple 
in  the  head  of  the  femur. 

4.  The  Transverse,  consisting  of  a  strong  flattened  band 


THE  ANATOMY   OF   THE   HIP.  39 

of  fibres  crossing  the  notch  at  the  lower  part  of  the  ace- 
tabulum,  thus  converting  it  into  a  foramen. 


Fig.  3. — FRONT  VIEW  OF  CAPSULAR  LIGAMENT. 

A.  Tendinous  band  between  vastus  externus  and  rectus  muscles,  strengthening 
capsule ;  B.  Ilio-femoral  ligament— the  Y-shaped  ligament;  C.  Thin  part  of  the  cap- 
sular  ligament. 

These  ligaments  are  deserving  of  a  more  detailed  descrip- 
tion, but  they  are  quite  fully  described  in  the  works  on 
anatomy. 

The  capsular  (see  Figs.  3  and  4)  encloses  the  cotyloid, 
the  ligamentum-teres  and  the  transverse,  springing  partially 
from  the  outer  fibres  of  the  last  mentioned.  The  whole  of 
the  joint  is  within  its  folds  and  the  varied  movements  at 
this  articulation  demand  a  targe  loose  capsule.  In  its 
lower  circumference  it  is  attached  in  front  to  the  spiral  or 
anterior  inter-trochanteric  line,  above  to  the  base  of  the 
cervix  femoris,  and  behind  to  the  middle  of  the  cervix,  a 
half  inch  from  the  inter-trochanteric  line.  Its  great  thick- 


40  DISEASES  OF  THE  HIP. 

ness  is  in  the  upper  and  forepart  of  the  joint  where  the 
greatest  amount  of  resistance  is  required.  Below  it  is  thin, 
loose  and  longer  than  in  any  other  part.  The  fibres  run 
in  two  directions,  a  longitudinal  and  a  circular.  The  cir- 
cular are  collected  into  a  band  at  the  lower  and  posterior 
portion,  where  they  embrace  the  femoral  neck,  while  in  front 


Fig.  4.— BACK  VIEW  OF  CAPSULE. 

A.  Zonular  fibres  at  back  of  capsule,  known  as  the  ischio-femoral  band;  B.  Thin 
part  of  capsule  attached  to  back  of  neck  of  the  femur. 

they  expand  and  are  interwoven  with  the  deeper  layers 
of  the  strongly  developed  longitudinal  fibres  and  are  by 
these  concealed.  The  longitudinal  are  most  distinct  as 
thick  bands,  serving  as  accessory  ligaments;  for  instance,  on 
the  anterior  and  superior  aspects  of  the  capsule,  known  as 
the  ilio-femoral  ligament  (B.  Fig.  3)  while  these  fibres  at  the 
lower  and  posterior  portion  of  the  joint  are  known  as  the 
ischio-femoral  (A.  Fig.  4)  passing  from  the  furrow  on  the 


THE  ANATOMY  OF  THE  HIP.  4! 

ischium  below  the  acetabulum  to  end  in  the  circular  band  of 
fibres.  In  front  likewise  there  is  a  band  converging  to  the 
capsule  from  the  ilio-pectineal  eminence  to  the  margin  of 
the  obturator  foramen  and  the  obturator  membrane,  known 
as  the  pectineo-femoral  ligament. 

The  capsule  is  additionally  strengthened  by  contact  with 
muscles  and  tendons  being  thus  supported  on  all  sides. 
Some  are  closely  connected  with  the  ligament,  and  serve 
to  raise  it  during  the  movement  of  the  joint,  thus  prevent- 
ing the  ligament  from  being  pushed  against  the  edge  of  the 
acetabulum. 

The  ilio-femoral.  band,  (B.  Fig.  3)  traverses  the  joint  in 
front,  extending  from  the  anterior  superior  spinous  process 
of  the  ilium,  to  the  anterior  trochanteric  line.  This  is 
called  the  Y-ligament  of  Bigelow,  from  its  appearance  on 
dissection.  Near  its  centre  is  an  aperture  transmitting  the 
transverse  branch  of  the  external  circumflex  artery  as  it 
passes  to  the  joint. 

This  accessory  ligament  or  band  limits  extension  and 
thus  prevents  the  natural  tendency  of  the  trunk  to  roll 
backwards  when  in  the  erect  posture.  Muscular  power  for 
this  purpose,  then,  is  not  required. 

Every  position  of  extension,  except  when  abduction  is 
combined  with  it,  renders  the  band  tense.  Adduction 
with  complete  extension,  outward  rotation  even  with  flex- 
ure, and  extension  with  outward  rotation  render  tense  the 
whole  ilio-femoral  band. 

Very  strong  fibres  make  up  the  ischio-femoral  band  (A. 
Fig.  4)  and  pass  in  almost  straight  lines  to  their  femoral 
attachment  when  the  thigh  is  flexed;  but  when  this  mem- 
ber is  extended  the  fibres  wind  upward  in  a  zonular  man- 
ner over  the  back  of  the  head  and  neck  of  the  femur.  This 
portion  of  the  capsular  ligament  does  not  limit  simple 
flexion  and  is  not  made  tight  until  adduction  or  rotation 
inwards  is  combined  with  flexion,  otherwise  it  is  quite  re- 
laxed. 

The  pectineo-femoral  band — a  narrow  set  of  fibres  pass- 
ing from  the  anterior  border  of  the  pectineal  eminence  to 
the  neck  of  the  femur — is  put  upon  the  stretch  in  abduction, 
whether  combined  with  flexion  or  extension,  and  is  very 
taut  both  in  abduction  combined  with  rotation  outward 
and  flexion,  and  in  abduction  combined  with  simple  flex- 
ion. 

A  triangular  space  bounded  by  the  ilio-femoral  and  the 


42  DISEASES  OF  THE  HIP. 

pectineo-femoral  bands  and  the  pubic  rim  of  the  ace- 
tabulum  is  the  thinnest  portion  of  the  whole  capsule,  but 
is  never  tightly  stretched  in  any  position  of  the  joint.  The 
ilio-psoas  muscle,  separated  by  a  bursa  which  occasionally 
communicates  with  the  synovial  sac,  passes  over  this  space. 

The  cotyloid  ligament  is  more  properly  called  by  Morris 
the  cotyloid  fibro-cartilage,  varying  in  depth  and  thickness, 
nowhere  more  than  a  quarter  of  an  inch  from  its  attached 
to  its  free  edge.  It  is  yellowish-white,  is  convex  on  its 
outer  surface,  while  its  articular  face  is  concave,  contract- 
ing somewhat  the  aperture  of  the  acetabulum,  so  that  it 
retains  the  head  within  its  grasp  after  the  capsule  and  all 
the  muscles  have  been  completely  divided.  It  is  so  closely 
blended  with  the  transverse  ligament  that  it  is  difficult  to 
speak  of  the  two  as  distinct  structures. 

In  both  of  its  aspects  it  is  covered  by  the  synovial  mem- 
brane, which  is  reflected  over  its  free  edge  from  the  cap- 
sule to  the  articular  cartilage  of  the  acetabulum. 

Mr.  Henry  Morris  (Anatomy  of  the  Joints,  and  Br.  Md. 
Jour.,  Nov.  28,1882,)  has  given  more  study  to  the  ligamentum 
teres  (Fig.  5)  than  any  one  of  the  recent  anatomists,  and  his 
observations  certainly  deprive  this  inter-articular  band  of 
much  of  the  importance  and  mysteriousness  with  which  it 
has  heretofore  been  enveloped. 

The  teres,  at  the  acetabulum,  has  two  bony  attachments, 
one  on  each  side  of  the  notch,  intermediate  fibres  springing 
from  the  under  surface  of  the  transverse  ligament  being 
continuous  herewith  the  capsular  ligament  and  periosteum 
of  the  ischium.  Its  attachment  to  the  caput  femoris  is  in  the 
anterior  part  (known  as  the  pit)  of  the  dimple  of  the  head, 
and  to  the  cartilage  forming  the  margin  of  this  part  of  the 
dimple.  The  ligament  is  from  an  inch  and  a-half  to  an 
inch  and  three-quarters  in  length,  and  varies  a  little  in  size 
in  proportion  to  the  thickness  of  the  ischio-femoral  band. 

The  fatty  tissue  at  the  bottom  of  the  rough  recess  in  the 
acetabulum  forms  a  thick  quadrangular  cushion,  occupying 
all  the  non-articular  portion  of  the  cavity,  and  projecting 
outwards  beneath  the  transverse  ligament  through  the 
acetabular  notch.  The  ligamentum  teres  receives  the  artic- 
ular nerves  and  arteries  as  they  enter  the  cavity  to  be 
transmitted  through  the  round  ligament  to  the  femur. 
The  thickness  of  the  synovial  membrane  in  its  reflection 
from  this  pad,  or  cushion,  to  the  ligament,  gives  it  the 
appearance  of  two  triangular  planes  at  right  angles  with 


THE  ANATOMY    OF  THE  HIP. 


43 


each  other.  This  interarticular  band  is  shut  out  from  the 
synovial  cavity  of  the  joint,  and  resembles  in  this  relation- 
ship the  lungs  and  the  abdominal  viscera. 

From  Mr.  Morris"  experiments  positive  proof  was  ob- 
tained "  that  (i)  the  ligamentum  teres  is  quite  relaxed  dur- 
ing extension  of  the  thigh,  and  that,  too,  whether  the  body 
lies  on  its  back,  or  is  raised  into  the  standing  posture;  (a) 
when  abduction  is  combined  with  extension  of  the  thigh 


FIG.  <;. — LIGAMENTUM  TERES. 

there  is  no  tension  on  the  round  ligament;  (3)  the  liga- 
ment is  at  its  tightest  when  the  limb  is  simultaneously 
flexed,  adducted,  and  rotated  outwards,  very  nearly  as 
tight  when  the  limb  is  fully  flexed  and  rotated  outwards 
without  being  adducted,  or  fully  flexed  and  adducted  with- 
out being  rotated  outwards." 

He  further  concludes  that  it  is  not  the  prime  function  of 
this  ligament  to  assist  in  supporting  the  weight  of  the 
body  in  the  erect  position,  whether  we  stand  on  one  leg  or 
on  both;  and  that  it  does  not  check  adduction  in  the  ex- 


44  DISEASES  OF  THE  HIP. 

tended  or  nearly  extended  position,  as  when  standing  at 
ease. 

It  has  been  shown  by  the  anatomist,  Hyrtl,  that  the  ves- 
sels which  pass  into  the  ligamentum  teres  from  without,  viz., 
one  from  the  obturator  artery,  and  the  other  from  the  in- 
ternal circumflex,  turn  back  in  loops  and  do  not  enter  the 
substance  of  the  head  at  all.  This  observation  has  been 
confirmed  by  other  anatomists,  and  we  are  led  to  doubt 
seriously  whether  it  is  the  primary  function  of  the  round 
ligament  to  convey  blood  to  the  head  of  the  femur.  In  the 
young  subject,  before  the  epiphysis  is  joined  to  the  dia- 
physis,  the  head  of  the  humerus  and  the  extremities  of  the 
other  long  bones  receive  their  blood-supply  without  any 
such  round  ligament,  and  in  the  adult  the  size  and  num- 
ber of  the  vessels  entering  the  neck  of  the  femur  seem 
amply  sufficient  to  nourish  also  the  head  of  the  bone. 

It  is  certainly  not  necessary  to  the  perfection  of  the  hip- 
joint  in  man,  by  reason  of  the  perfect  mobility  and  security 
of  the  joint  in  persons  who  have  been  born  without  this 
ligament,  and  by  the  successful  reduction  of  the  hip  after 
dislocation.  Its  secondary  importance  as  a  controlling 
structure  over  the  joint  is  further  proven  by  the  fact  that  it 
can  be  divided  without  causing  the  slightest  jerk  or  change 
in  the  position  of  the  limb  so  long  as  the  ilio-femoral  band 
is  intact.  Indeed,  comparative  anatomy  teaches  that  this 
ligament  is  but  the  tendon  of  the  ambiens  muscle. 

The  SYNOVIAL  MEMBRANE  lines  the  capsule  and  encloses 
the  ligamentum  teres  in  the  manner  already  described. 
Through  an  opening  in  the  anterior  wall  of  the  capsule  it 
sometimes  communicates  with  the  bursa  lying  beneath  the 
psoas.  This  membrane  is  quite  extensive,  but  is  well  pro- 
tected from  injury  by  reason  of  its  folds  and  connection 
with  the  mass  of  fat  in  the  basin  of  the  acetabulum.  The 
fluid  contained  within  its  cavity  does  not  differ  from 
synovial  fluid  in  general,  viz.,  either  colorless,  or  of  a  pale 
yellowish  tinge,  so  viscid  that  it  is  with  difficulty  poured 
from  one  vessel  into  another.  Robin,  as  quoted  by  Flint, 
gives  the  composition  as  follows:  water,  928.00;  synovine, 
(albumen)  64.00;  principles  of  organic  matter,  not  esti- 
mated; fatty  matter,  0.60;  chloride  of  sodium  and  carbon- 
ate of  soda,  6.00;  phosphate  of  lime,  1.50;  ammonio-mag- 
nesian  phosphate,  traces. 

THE  ARTICULATION. — The  hip  joint  is  a  ball  and  socket 
joint,  its  class  being  diarthrosis,  and  its  peculiar  subdivision 


THE  ANATOMY   OF  THE  HIP. 


45 


being  enarthrodia.  The  innominate  bone  furnishes  the 
cotyloid  cavity — the  acetabulum — in  which  snugly  fits  the 
globular  head  of  the  femur.  The  articular  portion  of  the 
acetabulum  is  shaped  like  a  horse-shoe,  is  covered  with  car- 
tilage, is  broader  above  and  behind  than  in  front,  and  is 
occupied  by  adipose  tissue  covered  with  synovial  mem- 
brane. The  acetabulum  is  formed  by  the  ilium,  a  little  less 
than  two  fifths;  the  ischium,  a  little  more  than  two  fifths, 
and  the  pubis,  the  remaining  one-fifth.  The  direction  of 
this  cavity  is  downward,  outward,  and  forward,  thus  re- 
ceiving the  head  of  the  femur  obliquely.  At  its  deepest 
part  the  bone  is  so  thin  that  light  is  transmitted,  while  the 
upper  and  posterior  wall  is  very  strong  and  very  thick. 
The  pelvic  surface  of  the  innominate  bone  corresponding 
to  the  floor  of  the  acetabulum,  presents  a  smooth  triangular 
plane,  from  which  the  obtu- 
rator membrane  and  the 
internal  obturator  muscles 
arise.  It  is  here  that  per- 
foration takes  place  in  articu- 
lar disease  of  the  hip,  and 
the  course  pus  takes  is  well 
illustrated  by  the  accom- 
panying diagram  I  have 
taken  from  Dr.  Clipping- 
dale's  essay  on  hip  -  joint 
disease,  published  in  the 
Medical  Press  and  Circular, 
1882-1883. 

The  circumference  of  the 
acetabulum  is  represented  by 
a  circle,  the  attachment  of  the 
obturator  muscle  by  a  dotted 
line.  It  is  obvious  that  a  per- 
foration of  the  acetabulum 
must  appear  internally  in  one  FIG.  6.— DIAGRAM  SHOWING  THE  COURSE 
Of  three  positions:  (A)  On  PusTAKES  IN  PERFORATION  OF  ACETABD- 

the  obturator  muscle;  (B)    in 

front  of  the  muscle;  (c)  behind  it.  If  the  opening  extend 
into  the  muscle  the  pus  will  pass  along  its  substance  and 
emerge  with  it  at  the  small  sciatic  notch,  and  point  upon 
the  nates.  A,  in  the  figure,  indicates  its  course:  If  per- 
foration have  occurred  behind  the  obturator  the  matter 
will  pass  into  the  ischio-rectal  fossa,  and  may  be  discharged 


46  DISEASES  OF  THE  HIP. 

either  through  the  perineum  or  into  the  rectum.  The  arrow 
B,  indicates  the  course  taken.  In  most  cases,  however,  the 
perforation  takes  place  anterior  to  the  origin  of  the  muscle, 
and  then  the  pus  passes  upwards  through  the  sheath  of 
the  obturator  vessels  and  makes  its  appearance  in  the 
groin.  Arrow  C,  indicates  the  course. 

The  development  of  the  innominate,  as  well  as  the  de- 
velopment of  all  bones  entering  into  the  formation  of 
joints,  is  of  prime  importance  in  the  pathogeny  of  bony 
diseases  in  the  neighborhood  of  articulating  surfaces. 

Ossification  begins  in  the  cartilage  of  the  ilium  just 
above  the  sciatic  notch  in  the  eighth  or  ninth  week.  Bone 
is  deposited  similarly  in  the  thick  part  of  the  ischium  be- 
low the  acetabulum  in  the  third  month,  and  in  the  su- 
perior ramus  of  the  pubis  in  the  fourth  or  fifth  month.  The 
greater  part  of  the  acetabulum,  the  crest  of  the  ilium,  the 
tuberosity  and  ramus  of  the  ischium,  and  the  body  and 
inferior  ramus  of  the  pubis  are  still  cartilaginous  at  birth. 
Ossification  from  the  three  primary  centres  has,  how- 
ever, extended  into  the  margin  of  the  acetabulum.  It  is 
not  until  the  seventh  or  eighth  year  that  the  rami  of  the 
ischium  and  the  pubis  become  completely  united  by  bone. 
Then  there  is  a  triradiate  strip  of  cartilage  known  as  the 
cartilage  in  the  floor  of  ths  acetabulum,  which  does  not  be- 
gin to  be  ossified  until  about  the  age  of  puberty. 

The  head  of  the  femur  forms  two  thirds  of  a  sphere, 
which  is  very  smooth,  being  covered  by  articular  cartilage. 
But  for  the  slight  bulging  at  a  spot  below  the  dimple  for 
the  round  ligament  it  forms  a  part  of  a  true  sphere.  The 
fossa  for  the  ligamentum  teres  is  below  and  behind  the 
middle  point  of  the  articular  surface  and  it  is  only  in  the 
anterior  part  of  the  fossa — the  pit — that  the  ligament  is 
attached,  while  it  lies  in  the  posterior  part — the  groove, 
when  in  action,  viz.,  flexion  with  outward  rotation.  The 
neck  is  cylindrical  near  the  head,  becoming  flattened  as  it 
proceeds  outwards.  Its  inclination  to  the  shaft  varies  in 
the  different  periods  of  life.  In  adult  life  the  angle  is  125° 
(Fig.  8).  In  early  life  it  is  about  135°  (Fig.  9).  The  angle 
is  not  so  obtuse  in  females  as  in  males.  As  age  advances 
it  approximates  a  right  angle.  In  bone  disease  there  takes 
place  also  this  change  in  the  angle.  The  posterior  and 
upper  half  of  the  great  trochanter  overhangs  the  neck  and 
in  the  angle  thus  produced  we  have  the  digital  fossa, 
into  which  the  tendon  of  the  external  obturator  is  inserted. 


THE  ANATOMY   OF  THE  HIP. 


47 


Numerous  large  foramina  for  the  passage  of  nutrient 
vessels  are  found  on  the  upper  surface  of  the  neck.  The 
length,  about  two  and  three-quarters  inches  behind,  and 
three  inches  below,  together  with  the  obliquity,  give  great 
leverage  to  the  muscles  inserted  into  the  trochanter,  and 
make  possible  a  wide  range  of  movement.  The  thigh  can 
be  flexed  so  that  its  anterior  surface  rests  on  the  anterior 
surface  of  the  abdomen.  Extension  in  a  child  can  be  car- 
ried about  ten  degrees  beyond  180°. 
Abduction  is  much  more  extensive  a 
movement  than  adduction,  the  one 
being  limited  by  the  striking  of  the 
upper  border  of  the  neck  of  the  femur 
against  the  upper  part  of  the  brim  of 
the  acetabulum,  while  the  other  is 
"stopped  almost  at  the  outset  by  the 
encounter  of  the  femur,  which  is  put 
in  motion  with  the  corresponding 
bone  of  the  other  side."  (Ward's  Out- 
lines of  Human  Anatomy,  p.  264.) 

If  the  opposite  limb  be  flexed,  how- 
ever, then  adduction  can  be  carried 
to  45°.  Circumduction  and  rotation 
are  important  movements. 

The  structure  of  the  head  and  neck 
is  peculiarly  adapted  to  receive  force. 
There  are  inverted  arches  converging 
towards  each  other  and  even  decus- 
sating. 

The  development  of  the  femur 
is  by  (i)  one  principal  ossific  centre 
for  the  shaft,  first  appearing  about  the 
seventh  week,  and  by  one  for  each  of 
the  four  epiphyses,  in  the  following 
order:  (2)  A  single  nucleus  for  the 
lower  epiphysis  appears  shortly  be- 
fore birth;  (3)  one  for  the  head  in  the 
first  year;  (4)  one  for  the  great  tro- 
chanter  in  the  fourth  year,  and  (5)  one 
for  the  small  trochanter  in  the  thirteenth  or  fourteenth 
year. 

The  neck  is  formed  by  extension  of  the  ossification  from 
the  shaft.  The  small  trochanter  is  united  to  the  shaft  by 
bony  union  about  the  seventeenth  year,  the  great  trochan- 


MENTOFTHE  FEMUR  BY  FIV 


48  DISEASES  OF  THE  HIP. 

ter  about  the  eighteenth,  the  head  from  the  eighteenth  to 
the  nineteenth  year,  and  the  lower  epiphysis  soon  after 
the  twentieth.  It  will  be  seen,  then,  that  at  birth  there  is 
only  a  single  epiphysis  in  which  ossification  had  already 
begun,  viz.,  the  lower  epiphysis.  The  physiological  devel- 


FIG.  8. — VERTICAL  SECTION  THROUGH  HIP-JOINT  OF  AN  ADULT.    (AFTER  MORRIS.) 

opment  is  very  rapid  in  the  upper  epiphysis  and  the  numer- 
ous large  foramina  in  the  neck  for  blood-vessels  shows  how 
rich  must  be  the  blood-supply.  The  accompanying  figure 
(9)  represents,  very  faithfully,  a  section  of  a  hip  in  a  boy 
eight  years  of  age.  The  angle  of  the  neck  and  shaft  is 
well  shown  by  comparison  with  the  adult  femur  in  Fig.  8. 
The  extent  of  cartilage  tissue  between  the  diaphysis  and 


THE  ANATOMY   OF  THE  HIP. 


49 


the  epiphysis  is  likewise   shown  by  comparison  with  the 
adult  section. 

In  fresh  specimens  taken  from  young  subjects  it  is  inter- 
esting to  note  the  physiological  hyperaemia.     The  ossific 


FIG.  9.— VERTICAL  SECTION  THROUGH  HIP-JOINT  OF  A  CHILD.  (MODIFIED  AFTER  MORRIS.) 

matter  is  not  so  hard,  and  the  intercellular  spaces  are  not  so 
sharply  defined.  Fig.  9  is  modified  from  Morris'  work,  the 
changes  being  made  from  a  specimen  I  have  in  my  posses- 
sion. Fig.  8  is  cooied  from  Morris,  without  change. 


CHAPTER  III. 

SPRAINS  AND  CONTUSIONS  OF  THE  HIP. 

The  popular  fallacy  so  prevalent  in  our  own  country  that 
hip-disease,  as  it  is  called,  is  caused  by  a  sprain  or  a  contu- 
sion, induces  me  to  devote  some  remarks  to  these  mishaps, 
great  and  small,  the  more  especially  as  my  records  are 
pretty  well  supplied  with  cases  which  I  propose  to  use  by 
way  of  illustration. 

By  sprain  is  understood  a  strain  or  wrench  to  some  of 
the  joint  structures,  the  ligaments  especially.  The  extreme 
freedom  of  movement  of  an  enarthrodial  joint,  like  that  of 
the  hip,  diminishes  the  liability  to  sprains.  There  are  certain 
sudden  movements,  however,  which  strain  not  only  the 
capsular  ligament  but  the  ligamentum  teres  also,  and  these 
do  occur  at  all  periods  of  life.  Extreme  abduction  com- 
bined with  flexion  renders  the  fibres  of  the  capsular  liga- 
ment tense,  and  falls  or  injuries  sustained  when  such  tension 
is  brought  to  bear,  may  cause  considerable  laceration  even 
of  these  structures.  When  sudden  flexion,  combined  with 
adduction  and  rotation  outwards  takes  place  the  ligamentum 
teres  is  very  liable  to  injury.  It  is  most  lax  in  abduction 
and  hence  cannot  suffer  sprain  in  the  very  common  po- 
sition of  the  limb  to  which  children  are  exposed  while  at 
play. 

The  ligaments,  however,  are  the  least  frequently  injured 
in  sprains  at  this  articulation  so  far  as  my  clinical  experi- 
ence teaches.  Generally,  I  find  the  muscles  near  or  at 
their  points  of  insertion  involved,  as  shown  by  manipula- 
tion and  traction.  It  requires  a  very  severe  wrench  to  in- 
flict serious  injury  on  the  ligaments,  so  well  are  they  pro- 
tected by  fascia,  cellular  tissue  and  muscles.  One  would 
naturally  suppose  that  the  nerves  would  participate  in  the 
sprain,  but  it  is  seldom,  in  my  own  practice,  that  I  am  able 
to  find  any  symptoms  of  nerve  lesion.  Occasionally  I  meet 
with  cases,  yet  they  are  rare.  It  is  different  in  contusions. 
In  the  case  of  a  boy,  aged  three  years,  whom  I  saw  October 
i,  1 88 1,  the  obturator  nerve  was  so  involved  that  temper- 


SPRAINS  AND  CONTUSIONS  OF  THE  HIP.  51 

ary  paralysis  ensued.  He  fell  three  days  before  this  date, 
from  a  window,  a  distance  of  twenty  feet,  striking  on  the 
right  side.  The  parents  searched  for  bruises  on  the  skin  and 
could  not  find  any.  He  walked  a  little  stiffly  the  same 
evening  and  was  fretful  during  the  night.  Next  day  he 
was  unable,  or,  refused  at  least,  to  walk  under  any  circum- 
stances. When  he  came  under  my  observation,  the  limb 
was  held  in  slight  flexion  at  the  hip,  and  on  attempting 
outward  rotation,  resistance  was  encountered.  Joint  ten- 
derness was  quite  a  marked  feature,  and  on  rotating  the 
limb  I  detected  a  distinct  grating,  not  albuminoid,  be- 
tween the  head  of  the  femur  and  the  acltabulum.  There 
was  very  little  muscular  resistance,  no  atrophy,  and  no 
shortening  of  the  limb.  No  paralysis  was  discovered  at 
this  time. 

My  diagnosis  was  a  contusion  of  the  joint,  and  the  peri- 
articular  tissues  seemed  to  have  escaped.  The  position  of 
the  limb  was  readily  explained  by  reflex  muscular  action. 

A  spica  bandage  with  cotton  batting  underneath  was 
applied  and  the  patient  was  ordered  to  bed.  On  the 
seventh,  a  week  later,  the  reflex  symptoms  had  subsided, 
and  the  child  was  able  to  stand  without  difficulty.  The 
treatment  was  continued,  and  on  the  eleventh  he  was  walk- 
ing, but  there  was  a  marked  limp  in  the  gait  and  the 
reflex  symptoms  had  recurred,  although  they  were  present 
only  on  movement  of  the  joint,  as  in  walking.  Six  days 
later  I  found  the  boy  walking  as  if  the  limb  were  weak 
and  the  calf  was  nearly  a  half  inch  smaller  than  its  fellow. 
The  limb  tottered  as  he  stepped  and  there  seemed  to  be 
paralysis  in  the  muscles  supplied  by  either  the  obturator  or 
the  sacral.  Faradism  was  employed  for  a  few  weeks  and 
on  the  nineteenth  of  January  he  was  discharged  cured. 
The  gait  was  perfect  and  there  was  no  joint  tenderness.  I 
saw  him  again  on  the  last  day  of  the  month,  and  there  was 
no  relapse. 

Now  in  this  case,  in  the  absence  of  fuller  notes  on 
the  day  I  recorded  an  apparent  paralysis,  I  am  unable  to 
decide  whether  the  paralysis,  or,  paresis,  was  due  reflexly  to 
injury  of  the  articular  terminal  fibres  of  the  obturator,  or 
branches  of  the  sacral,  or  directly  from  contusion  of  the  sci- 
atic as  it  passes  behind  the  trochanter.  The  muscular 
spasm  was  certainly  reflex  and  a  sufficient  cause  is  found 
therefor  if  we  suppose  that  the  articular  nerve-terminals 
were  injured. 


52  DISEASES   OF  THE   HIP. 

The  symptoms  of  sprain  depend  materially  on  the  tissues 
injured,  and  frequently  so  many  are  implicated  that  a  clini- 
cal picture  is  difficult  to  paint.  Of  course  pain  immediately, 
on  the  receipt  of  the  fall  or  wrench  is  to  be  expected,  yet 
sometimes  a  day  elapses  before  this  symptom  arises.  The 
fact  that  in  chronic  bone-disease  of  the  hip  lameness  is 
often  the  only  sign  for  several  weeks  furnishes  a  strong  ar- 
gument against  the  traumatic  theory  in  the  etiology  of  the 
same. 

In  young  children  the  crying  and  fretting  and  disturbed 
sleep  so  common  within  the  first  twelve  hours  after  a  severe 
fall  are  too  well  known  and  must  be  construed  as  indicative 
of  immediate  pain.  In  adults  this  is  distinctly  complained 
of  in  the  beginning.  A  carpenter,  forty-two  years  of  age, 
in  1881  fell  a  distance  of  twelve  feet,  the  upper  portion  of 
his  left  thigh  coming  in  contact  with  a  ladder.  He  exper- 
ienced a  sharp  pain  in  the  hip,  and  this,  with  a  marked 
lameness,  continued  up  to  the  time  I  saw  him,  six  months 
afterwards.  Indeed,  he  had  a  severe  contusion  of  the 
hip  which  kept  him  confined  to  bed  in  a  hospital  a  few 
weeks,  and  compelled  him  to  resort  to  crutches  after  leav- 
ing the  institution.  He  was  on  crutches  when  I  first  saw 
him,  and  I  examined  the  limb  with  much  care,  finding  only 
a  half-inch  atrophy,  no  shortening,  and  a  smoothness  of 
joint  surfaces.  The  movements  were  not  resisted  unless 
carried  to  extremes,  and  then  he  winced.  My  impression 
was  that  he  had  strained  some  fibres  of  the  capsular  liga- 
ment, as  well  as  contusing  the  joint.  The  one  thing  he 
complained  of  most  was  the  persistent  pain  and  deep  sore- 
ness in  the  groin.  Under  the  hot  douche  by  day,  and  hot 
fomentations  by  night,  he  gave  up  his  crutches  at  the  end 
of  two  months  and  then  faradism  was  employed  daily. 
His  improvement  has  been  slow,  yet  he  is  now  free  from 
pain  and  moves  about  very  easily  without  artificial  support. 

The  signs  which  one  finds  often  correspond  closely  with 
those  found  in  the  early  stage  of  joint-disease,  and  a  differ- 
ential diagnosis  sometimes  becomes  very  hard  to  make.  If, 
however,  the  history  of  the  fall  be  clear  and  the  symptoms 
immediately  succeeding  be  unmistakable,  the  diagnosis  is 
easily  made.  These  are  so  often  imperfectly  remembered, 
and  so  often  become  insignificant  under  a  rigid  cross-exam- 
ination that  one  must  rest  content  with  a  provisional  diag- 
nosis, and  keep  the  case,  for  a  while  at  least,  under  close 
observation. 


SPRAINS  AND   CONTUSIONS  OF  THE  HIP.  53 

A  boy,  five  and  a  half  years  of  age,  was  brought  to  the  hos- 
pital on  the  eighteenth  of  July,  walking  quite  lame,  with  ten- 
derness in  the  left  groin,  but  not  behind  the  trochanter.  The 
natis  was  changed  a  little  in  contour,  and  muscular  resistance 
was  offered  when  flexion,  extension  and  rotation  both  in- 
ward and  outward,  were  carried  near  the  full  normal  limits. 
In  other  words,  he  gave  many  of  the  signs,  on  testing  the 
functions  of  the  limb,  that  one  gets  in  the  first  stage  of 
chronic  articular  ostitis.  On  inquiry  it  was  learned  that 
the  boy  was  perfectly  well  and  free  from  lameness  on  the 
twelfth,  when  he  had  a  fall  while  at  play.  He  walked 
lame  immediately  thereafter  and  complained  of  pain.  In 
a  day  or  two  these  symptoms  subsided,  and  he  had  an- 
other fall,  spraining  the  same  hip.  A  sprain  was  the  diagno- 
sis, followed  by  an  interrogation  point,  and  a  roller  was  ap- 
plied by  way  of  assisting  in  securing  the  desirable  rest.  In 
four  days  the  pain  had  disappeared  and  the  contour  of  the 
nates  was  normal.  Nearly  two  years  afterwards  I  traced 
the  case  out  and  found  that  all  symptoms  had  disappeared 
shortly  after  the  date  of  my  last  note,  and  that  he  remained 
free  from  pain  or  lameness  for  twelve  months,  when  he 
received  a  contusion  over  the  same  hip,  and  was  lame  about 
three  days. 

In  1878,  the  month  of  October,  a  little  girl,  three  and  a 
half  years  of  age,  a  thin,  exceedingly  cross-looking  specimen 
of  humanity,  was  brought  presenting  a  marked  degree  of 
lameness.  In  fact  the  child  seemed  unable  to  walk  except 
by  the  aid  of  a  chair.  The  joint  was  fairly  locked,  so  great 
the  muscular  resistence  when  movements  were  attempted  in 
any  direction.  There  was  no  :.nfiltration  or  signs  of  con- 
tusion in  the  soft  parts.  A  veek  before  this  she  fell  from 
the  hand-rail  of  a  staircase,  striking  on  the  left  side,  and  no 
bruises  could  be  found,  but  she  cried  a  little  at  the  time. 
That  night,  and  on  subsequent  nights,  the  sleep  was  undis- 
turbed. Putting  on  shoes  and  stockings  caused  no  cries  or 
wincing.  Only  she  refused  to  walk.  Rest  and  a  liniment 
were  ordered,  a  simple  sprain  having  been  diagnosticated. 
The  patient  did  not  return  as  directed,  and  fourteen  months 
afterwards  I  found  her  free  from  lameness  and, in  excellent 
-^health.  All  symptoms  had  disappeared  shortly  after  the 
visit  to  the  hospital.  These  sprains  assume  vast  proper, 
tions  when  the  child  injured  is  a  few  years  older  than  these 
two,  and  prospects  of  damages  from  a  landlord  or  a  wealthy 
corporation  are  held  out  by  some  hungry  member  of  the 


54  DISEASES   OF   THE   HIP. 

bar.  The  diagnosis  then  becomes  extremely  difficult  and 
prognostications  signally  fail.  Take  the  following  as  an  in- 
stance: In  the  month  of  February,  1880,  a  thirteen-year-old 
lad,  muscular  and  well  developed,  came  from  a  neighboring 
county  to  the  hospital  with  his  parents,  plain  laboring  peo- 
ple of  foreign  birth.  My  examination  was  made  with 
much  care.  He  stood  with  limbs  parallel,  the  right  foot 
however  inclined  to  inversion,  i.e.,  he  would  from  time  to 
time  assume  this  attitude,  and  as  he  walked  the  foot  would 
be  inverted  although  the  lameness  was  scarcely  percepti- 
ble. He  could  stand  resting  all  of  his  weight  on  either  limb 
without  pain  or  inconvenience,  but  when  questioned  as  to 
the  locality  of  symptoms  he  would  complain  of  soreness  in 
the  right  groin  and  down  the  outer  side  of  the  thigh  as  far 
as  the  lower  third.  There  was  no  infiltration  any  where  to 
be  found;  flexion,  extension,  abduction,  adduction,  and  ro- 
tation were  made'  to  the  extreme  limits,  without  increase 
of  soreness  and  without  muscular  resistance.  The  limbs 
were  equal  in  size  and  length,  and  I  could  not  by  any  test 
elicit  joint-tenderness.  There  was  tenderness  along  the 
iliac  crest,  and  the  superficial  inguinal  glands  were  a  little 
enlarged. 

The  history  given  was  that  one  day — a  month  before — 
while  riding  in  a  cart  over  a  rough  road,  by  a  sudden  jolt  he 
was  thrown  against  an  iron  bar  in  the  cart,  the  right  hip  re- 
ceiving the  shock  of  the  concussion.  He  walked  well  on  get- 
ting out,  and  did  not  complain  of  pain.  Next  day  he  com- 
plained of  pain  in  the  right  foot  and  was  unable  to  wear  his 
boot.  There  was  a  certain  lameness  present,  too,  with  in- 
version of  the  foot,  and  these  symptoms  not  subsiding  by 
the  end  of  a  week  a  physician  was  consulted,  who  stated,  so 
the  mother  says,  that  the  "  hip  was  out  of  place,"  and  after 
efforts  at  reduction  claimed  to  have  succeeded.  At  all 
events  he  got  relief  from  pain  and  lameness  from  these 
manipulations.  A  week  elapsing,  he  had  pain  referred  to 
the  hip  and  the  knee,  and  the  foot  again  became  inverted 
as  he  walked.  This  last  is  the  only  constant  symptom. 
Since  the  accident  he  has  had  a  little  nocturnal  eneuresis. 
I  confessed. my  inability  to  make  a  diagnosis  and  as  the 
mother  was  desirous  of  getting  the  boy  into  the  hospital  he 
was  admitted.  A  fly-blister  was  applied  in  the  inguinal 
region  that  night,  poultices  followed  during  the  next  three 
days,  and  by  the  end  of  February  all  soreness  and  inversion 
of  foot  had  disappeared.  He  was  retained  in  the  hospital 


SPRAINS  AND  CONTUSIONS  OF  THE   HIP.  55 

ten  days  longer,  when  a  careful  examination  failed  to  de- 
tect any  symptoms  whatever.  On  this  date  he  walked 
about  twenty  blocks,  after  which  he  was  lame  again,  the 
lameness  continuing  two  weeks,  when  he  was  readmitted  to 
hospital  in  the  same  condition  as  before.  A  liniment  and 
a  spica  constituted  the  treatment,  and  March  2pth  I  made 
a  note  that  his  lameness  differed  from  that  on  the  former 
occasion  in  that  he  walked  on  the  toes  and  the  ball  without 
the  inward  rotation. 

He  was  to  every  appearance  restored  by  April  2d,  but 
was  under  daily  observation  until  the  3oth,  without  a  symp- 
tom. He  was  then  discharged.  It  was  reported  on  May 
8th  that  he  had  been  lame  for  eight  days,  and  in  June  I  found 
the  lameness  and  eversion  still  present.  I  sent  him  to  see 
Dr.  Frank  Hamilton,  who  wrote  me  "I  think  the  internal 
rotators  are  partially  paralyzed;  he  can  turn  the  leg  in  if  he 
tries."  It  was  about  this  time  we  learned  that  a  suit  had 
been  instituted  against  the  town  corporation  for  damages 
sustained  by  virtue  of  the  road  being  out  of  repair.  In  fact  I 
was  asked  to  appearas  witness  in  the  cause.  This  suit  I  dis- 
couraged by  stating  I  could  not  testify  to  any  specific  lesion, 
and  af-ter  a  year's  delay,  I  think,  the  cause  was  dismissed. 
During  this  time,  too,  under  the  delays  and  uncertainties  of 
the  law,  the  lameness  gradually  disappeared,  and  to  my 
mind  these  curious  relapses  became  satisfactorily  explained. 

It  is  something  remarkable,  however,  the  heights  from 
which  a  child  can  sometimes  fall  without  sustaining  cor- 
responding injury.  Quite  a  number  of  such  cases  have 
come  under  my  own  observation  and  it  has  been  rare  to 
find  any  joint  disease  resulting.  Severe  contusions  of  the 
soft  parts,  and  occasionally  of  the  bone,  have  been  about 
the  only  lesions  I  could  detect.  A  girl,  aged  three  and  a 
half  years,  wa?s  brought  to  me  in  July,  1877,  with  a  contusion 
of  the  left  thigh.  It  was  stated  that  two  days  before  this 
she  fell  from  a  third-story  window  of  a  tenement  house 
into  the  back  yard,  probably  striking  in  her  descent  a 
clothes  line  which  broke  the  fall.  She  was  picked  up  uncon- 
scious, though  she  soon  recovered  from  this  state.  The 
t  forehead  had  sustained  a  lacerated  wound.  No  other  in- 
juries were  found,  but  the  child  refused  to  walk  and  com- 
plained of  pain  in  the  left  loin.  I  found  the  thigh  one  inch 
larger  than  its  fellow  and  a  resistance  to  complete  exten- 
sion at  the  hip.  There  was  no  shortening,  no  discoloration 
no  fracture. 


56  DISEASES  OF  THE   HIP. 

I  did  not  see  her  again  until  the  4th  March,  1883,  an 
interval  of  nearly  six  years  having  elapsed,  and  I  found  that 
she  had  made  a  speedy  and  a  perfect  recovery.  No  traces 
of  the  former  injury  could  be  discovered. 

In  the  month  of  August,  1875, 1  saw  a  girl,  aged  five  years, 
who  had  fallen  a  few  days  before  from  the  fourth-story 
window  into  a  gutter,  striking,  as  she  fell,  a  shutter  on  a 
third-story  window.  The  left  limb,  when  I  examined  her, 
was  rotated  outward,  and  there  was  great  prominence  of 
the  upper  third  of  the  femur.  I  could  not  detect  any  crepi- 
tus  articular  or  periarticular,  and  there  was  no  shortening. 
She  walked  with  a  marked  limp,  yet  seemingly  without 
pain.  The  different  diagnoses  I  succeeded  in  getting  from 
gentlemen  who  examined  the  case  with  me  were:  (i)  prob- 
able fracture  of  the  neck,  near  trochanter,  (2)  hip-disease, 
(3)  fracture  of  the  pelvis,  and  (4)  relaxation  of  the  ligaments. 

The  treatment  was  purely  expectant,  and  I  contented 
myself  with  examining  the  case  from  time  to  time  and  re- 
cording my  observations.  In  January,  1876,  I  recorded  the 
same  signs  as  on  the  first  date,  with  the  exception  that  her 
gait  had  materially  improved.  Attacks  of  diphtheria  (?) 
and  scarlet  fever  in  the  spring  of  that  year  were  followed 
by  suppurating  cervical  glands,  but  the  functions  of  the 
limb  suffered  no  impairment.  In  the  month  of  January, 
1883,  after  a  lapse  of  nearly  seven  years,  I  made  an  exami- 
nation, finding  the  same  prominence  of  the  femur  in  its 
upper  portion  looking  very  much  like  the  deformity  of  a 
dislocation  or  a  diastasis.  Yet  I  could  not  detect  any  short- 
ening or  any  atrophy.  The  head  of  the  bone  was  in  the 
acetabulum,  and  there  was  normal  smoothness  of  the  articu- 
lar surfaces.  The  movements  were  perfect  in  all  directions 
save  in  extreme  outward  rotation.  The  child  was  free 
from  pain  and  walked  without  any  lameness.  The  diag- 
nosis to  which  I  was  led  was  that  she  had  sustained  an  in- 
complete fracture  of  the  thigh  in  its  upper  fourth  and  that 
a  degree  of  tortion  took  place  at  the  same  time. 

I  trust  that  by  the  narration  of  these  cases  the  diagnosis 
has  been  made  sufficiently  clear,  and  I  pass  now  to 

TREATMENT,  which  need  not  occupy  much  space.  In  re- 
cent sprains  all  recognize  the  value  of  rest,  and  Nature  her- 
self seems  to  enforce  this  great  principle.  I  have  been  in 
the  habit  of  using  a  spica  bandage  with  infrequent  changes, 
and  this  simple  measure  assists  much  in  securing  the  rest 
desired.  I  discourage  all  attempts  at  walking,  and  insist  on 


SPRAINS  AND  CONTUSIONS  OF  THE   HIP.  57 

the  child  being  confined  to  bed  or  the  nurse's  arms  until  the 
soreness  has  been  removed.  If  the  soft  parts  have  been  con- 
tused cold  or  hot  dressings  will  naturally  suggest  them- 
selves. A  nineteen-month-old  child  came  under  treatment 
November  i2th,  1879,  with  a  history  of  a  fall  on  the  6th, 
in  the  doorway,  the  foot  turning  under  her  as  she  fell. 
The  child  had  been  walking  about  five  weeks  only.  She 
cried  bitterly  for  about  two  hours  and  then  fell  asleep. 
There  has  been  no  disposition  to  use  the  limb  and  move- 
ments at  the  hip  aggravate  the  pain.  She  cries  much  dur- 
ing sleep  and  holds  the  thigh  flexed.  I  found  that  motion 
at  the  hip  was  free  and  painless  in  flexion  and  rotation,  but 
not  so  in  complete  extension.  There  was  no  shortening  or 
atrophy  or  infiltration  of  the  parts  about  the  joint.  One 
year  previously  a  brother  four  years  of  age  developed 
chronic  articular  ostitis  of  the  hip,  which  was  in  the  sup- 
purative  stage. 

Notwithstanding  this  fact,  I  diagnosticated  a  sprain,  and 
the  mother  was  enjoined  to  move  the  limb  as  little  as  pos- 
sible. A  snugly-fitting  roller  was  applied,  and  was  not  re- 
moved until  the  i5th,  the  date  of  the  next  visit,  when  it  was 
noted  that  the  deformity  was  less  marked.  I  refrained 
from  any  manipulations,  but  reapplied  the  roller  with  cot- 
ton batting  beneath,  and  directed  the  same  care  in  hand- 
ling as  before.  In  four  days  more  the  case  was  considered 
cured.  The  motions  at  hip  were  perfect  and  the  child  stood 
without  any  deformity.  The  roller  was  to  be  continued  a 
week  longer.  There  was  no  further  treatment,  the  case 
making  a  good  recovery,  as  proven  by  examination  in  Janu- 
ary 1880. 

The  treatment  of  contusions  is  practically  the  same  as  of 
sprains.  Rest  is  the  sine  qua  non,  and  the  diagnosis  once 
established  frequent  examinations  are  to  be  discouraged. 

The  necessity  for  breaking  up  stiff  hip-joints  that  depend 
on  ligamentous  strain  and  periarticular  adhesion,  does  not 
often  arise,  especially  in  childhood.  In  other  joints,  for 
instance,  lying  more  superficial  and  limited  naturally  less 
in  movements  than  the  hip,  these  adhesions  form.  It  gen- 
erally happens,  however,  that  stiff  hip-joints  in  children, 
when  broken  up  by  force,  done  as  a  rule,  under  the  im- 
pression that  the  lesion  is  a  result  of  a  sprain,  do  badly  and 
cause  the  surgeon  a  deal  of  regret.  He  has  egregiously 
erred  in  diagnosis,  and  the  original  lesion  has  been  hastened 
into  an  advanced  stage, 


58  DISEASES  OF  THE  HIP. 

Not  so,  however,  in  adults,  who  suffer  severe  sprains  at 
this  joint.  The  reparative  process  is  much  slower,  and  ad- 
hesions do  somehow  form,  wherein  brilliant  results  are 
attained  by  vigorous  passive  motion  under  an  anaesthetic. 

I  think  I  am  stating  a  rule  that  every  careful  surgeon  will 
approve  and  that  every  careful  surgeon  observes  when  I  state 
that  brisement  force  is  seldom  or  never  indicated  in  the  stiff 
hips  seen  in  early  life.  If  they  depend  on  a  sprain,  time  and 
locomotion  and  play  will  accomplish  all  that  is  desired,  and 
a  prognosis  as  to  the  perfect  restoration  of  function  may  in 
nine  cases  out  of  ten  be  safely  made.  If  the  limitation  of 
function  depend  on  a  periarthritis  the  same  natural  means 
will  operate  to  bring  about  a  perfect  recovery. 

If,  however,  there  be  a  bone  lesion,  either  central  or  peri- 
pheral, undoubted  damage  will  be  done  and  the  future  use- 
fulness of  the  joint  jeopardized. 

It  is  better  to  wait  and  allow  enough  time  to  elapse  to 
settle  the  question  as  to  diagnosis.  In  chronic  articular  os- 
titis,  the  intervals  between  the  exacerbations  are  so  harm- 
less in  their  symptoms  and  the  lameness  is  so  persistent 
that  the  temptation  comes  with  great  force  sometimes  to 
attempt  relief  under  an  anaesthetic.  Cases  are  sent  to  me, 
not  infrequently  with  notes  from  the  attending  physician, 
asking  whether  it  would  not  be  good  practice  to  make  an 
attempt  at  overcoming  this  little  stiffness  left  over  from  an 
ancient  injury.  The  cases  are  nearly  always  in  children 
whose  parents  have  given  so  clear  a  history  of  trauma  that 
the  doctor  really  believes  such  to  be  the  exciting  cause,  and 
invariably  I  find  a  chronic  bone-disease,  at  or  near  the  joint, 
in  one  of  the  stages  of  slow  evolution. 


CHAPTER  IV. 
NEUROSES  OF  THE  HIP. 

"  Neuroses,  ....  a  generic  name  for  diseases  sup- 
posed to  have  their  seat  in  the  nervous  system,  and  which 
are  indicated  by  disordered  sensation,  volition,  or  men- 
tal manifestation  :  without  any  evident  lesion  in  the  struc- 
ture of  the  parts,  and  without  any  material  agent  pro- 
ducing them.  Such  is  the  usual  definition.  Broussais  at- 
tributes them  to  a  state  of  irritation  of  the  brain  and  spinal 
marrow." — Dunglison. 

Such  is,  I  am  well  convinced,  the  recognized  meaning  of 
the  term  among  neurologists,  and  clinicians  generally  have 
found  it  very  useful  and  a  very  convenient  name  to  employ. 
Formerly  a  neurosis  carried  with  it  a  pathological  signi- 
ficance of  some  kind  not  always  understood,  but  latterly  it 
has  come  to  represent  a  class  of  functional  disturbances  of 
the  nervous  system,  and  the  definition  at  the  head  of  the 
chapter  fairly  expresses  the  sense  it  conveys.  In  addition 
to  the  indications  specified  in  the  quotation  by  which  these 
nervous  phenomena  are  manifested  I  would  add  reflex  mus- 
cular spasm,  chiefly  tonic, 

The  term  associated  with  the  hip  is  intended  to  convey 
to  the  minds  of  my  readers  the  fact  that  there  are  many 
pseudarthropathies  of  the  hip  wherein  the  neural  element 
is  so  prominent  that  we  speak  of  them  as  neurotic.  There 
are  many  cases  purely  hysterical,  and  we  speak  of  these 
as  such,  and  again  there  are  instances  in  which  the  symptoms 
are  feigned  or  counterfeited  so  closely  that  we  speak  of 
such  as  cases  of  neuromimesis.  Sir  James  Paget,  in  "  Clin- 
ical Lectures  and  Essays,"  published  in  1875,  employed  this 
latter  term  and  illustrated  the  subject  by  some  cases  quite 
remarkable.  Skey,  in  a  series  of  lectures  published  in  1867, 
called  these  joint  affections  hysterical — as  did  Sir  Benjamin 
Brodie  years  before.  Indeed,  Sir  Benjamin  says:  "I  do  not 
hesitate  to  declare  that  among  the  higher  classes  of  society 
at  least  four-fifths  of  the  female  patients  who  are  commonly 
Supposed  to  labor  under  disease  of  the  joints,  labor  undef 


60  DISEASES  OF  THE  HIP. 

hysteria  and  nothing  else."  Esmarch,  whose  name  is  associ- 
ated with  so  much  that  is  grand  and  abiding  in  surgery, 
fode  atone  time  the  hysterical  hobby,  and  (Dr.  Shaffer — Hy- 
sterical Elements  in  Orthopedic  Surgery — is  my  authority 
for  stating  this,)  fully  indorsed  this  assertion  of  Brodie. 
Esmarch,  however,  adopted  to  my  mind  the  more  compre- 
hensive term — viz.,  gelenkneurose,  and  his  publication  at  Kiel 
in  1872  was  entitled  "Ueber  Gelenkneurosen."  M.  Charcot 
and  S.  Weir  Mitchell  have  embellished  this  subject,  and  in- 
deed the  literature  of  neurology  contains  much  that  relates 
to  the  various  disturbances  in  nutrition  and  sensation. 
Hysterical  contractions  are  very  common  in  neurological 
and  gynecological  medicine.  The  neurological  specialist  is 
too  prone,  I  think,  to  attribute  real  arthropathies  to  neuroses, 
and  the  Cases  of  tabes  dorsalis  with  bone  and  joint  lesions 
so  well  elaborated  by  Charcot,  certainly  furnish  strong  ana- 
logical evidence  that  some  at  least  of  the  joint  diseases  with 
which  the  orthopedist  comes  in  contact  are  neural  in  origin. 
The  late  Dr.  Jno.  K.  Mitchell  of  Philadelphia  and  his  illus- 
trious son,  whose  name  I  have  already  mentioned,  have  fur- 
nished many  illustrations  showing  the  connection  between 
spinal  lesions  and  joint  lesions. 

The  subject  is  a  fascinating  one  to  the  orthopedist,  and  he 
eagerly  grasps  at  any  cause  the  knowledge  of  which  will 
help  him  to  so  easily  solve  some  of  the  harassing  problems 
of  this  particular  specialty.  In  the  early  part  of  the  last 
decade  I  became  exceedingly  interested  in  nervous  diseases, 
and  I  studied  many  cases  that  lay  on  the  border-line  of 
neurology  and  orthopedy.  Many  instances  of  apparently 
formidable  joint  affections  I  could  trace  to  a  spinal  or  neural 
origin,  and  I  obtained  speedy  cures  with  this  knowledge  at 
hand. 

In  1877  I  published  a  paper  that  I  had  presented  to  the 
American  Neurological  Association  on  the  subject  with 
which  1  am  now  dealing,  and  in  it  gave  my  conclusions 
based  on  a  study  of  some  forty  cases  of  true  and  false  ar- 
thropathies. The  subject  was  brought  prominently  before 
the  members  of  my  own  specialty  at  that  time.  In  1879 
Dr.  Shaffer  collected  his  own  cases,  read  a  paper  on  "  Hys- 
terical Joint  Affections,"  before  the  New  York  Neurological 
Society,  and  brought  it  out  in  the  shape  of  a  monograph  in 
1880. 

From  a  reported  case  or  two  in  the  volume  one  can  infer 
that  the  author  appreciated  the  danger  of  being  carried 


NEUROSES  OF  THE  HIP.  6l 

away  by  enthusiasm.  My  own  enthusiasm  when  at  work 
over  my  cases  a  few  years  before  this  period  led  me  sub- 
sequently into  occasional  error,  and  I  am  now  very  scep- 
tical about  the  causative  relationship  between  neuroses  and 
true  bony  lesions  of  the  hip  joint;  so  that  my  present  chapter 
on  this  subject  will  deal  purely  with  the  false  arthropathies 
of  neural  origin. 

Dr.  Shaffer  has  placed  on  record  some  valuable  cases, 
which  I  shall  take  the  liberty  of  using  in  connection  with 
my  own.  It  is  difficult  to  discuss  the  pathological  phases 
of  this  subject,  for  the  reasons  already  given,  and  I  propose 
now  to  illustrate  the  clinical  history  by  means  of  cases. 
The  following  appeared  in  my  paper  in  1877,  and  was  that 
of  a  boy  aged  eleven  years,  who  was  brought  to  the  out- 
door department  of  the  hospital  in  March,  1877,  for  sus- 
pected hip-disease.  A  hasty  examination  was  made,  and  a 
day  set  for  his  admission  as  an  in-patient.  The  mother  was 
assured  that  the  lesion  was  spinal,  and  a  fair  prognosis  was 
given.  No  history  was  recorded  at  the  time,  but  this  was 
deferred  until  his  admission.  The  next  day,  however,  by 
the  unsought  advice  of  a  kindly  disposed  aunt,  the  child 
was  taken  to  an  orthopedic  expert,  a  consultation  was  held, 
and  double  hip-disease  was  diagnosticated.  (This  was 
volunteered  testimony  on  the  part  of  the  mother  and  the 
aforesaid  aunt.)  I  simply  make  mention  to  illustrate  a  dif- 
ficulty in  making  a  differential  diagnosis. 

On  the  27th  March,  admitted  to  the  hospital,  when  it  was 
learned  that  the  father,  after  a  long  illness  had  died  of 
phthisis,  and  that  two  other  children  in  the  family  had  died 
of  some  acute  intracranial  disease — in  fact,  no  better  stru- 
mous  history  could  have  been  obtained.  The  patient  has 
ever  been  healthy,  prior  to  the  middle  of  the  preceding 
month.  Then,  without  any  known  exciting  cause,  he  com- 
plained of  pain  in  the  right  knee;  shortly  afterward  of  pain 
in  both  knees,  and  in  back.  To-day,  as  he  walked,  one 
limb  for  a  while  was  favored,  then  the  other.  His  chest 
was  found  somewhat  rachitic,  auscultation  furnished  ne- 
gative results.  At  one  time  he  stands  so  that  a  marked  left 
skoliosis  presents  itself,  at  another  vice  versa.  In  other 
words,  one  position  quickly  fatigues.  Tenderness  on  pres- 
sure over  spinous  processes  of  sixth,  seventh,  and  eighth 
dorsal  vertebrae,  more  marked  as  that  of  the  ninth  is 
reached,  becoming  excessively  so  over  those  of  the  lumbar. 
Pressure  over  trochanters,  lateral  ligaments,  and  malleoli 


62  DISEASES  OF  THE  HIP. 

of  both  lower  extremities,  gives  pain.  Flexion,  ab-  and  ad- 
duction of  either  thigh,  is  resisted  by  muscular  spasm.  Hy- 
peraesthesia  is  a  prominent  symptom.  No  swelling  or  effu- 
sion of  any  kind  is  found,  periarthritic,  and  when  the  limb 
is  grasped  firmly  and  motion  made,  no  pain  in  any  joint  is 
perceived.  There  is  no  arthropathy,  and  the  former  diag- 
nosis stands  unamended.  An  emplastrum  cantharidis  to  the 
spinal  tenderness  is  all  that  is  prescribed. 

Four  days  later  very  little  tenderness  remained.  On  the 
7th  of  April  it  was  recorded  that  he  walks  with  perfect  ease, 
no  limp  being  discoverable.  No  spinal  tenderness  at  any 
point;  no  tenderness  anywhere.  On  the  i6th  he  was  cured 
and  on  the  lyth  discharged. 

The  recurrence  of  symptoms  after  long  remissions  is  not 
uncommon,  and  occasionally  we  have  an  opportunity  of 
observing  the  case  through  two  or  more  exacerbations.  A 
boy,  for  instance,  aged  four  and  a  half  years,  came  under 
my  care  in  the  spring  of  1876,  presenting  a  stiffness  in  the 
lumbar  spine,  without  tenderness  or  deformity.  There  was 
a  moderate  contraction  of  the  psoas,  left  side.  The  boy 
had  been  resting  poorly  at  night,  and  walking  with  a  limp 
for  three  months.  A  history  was  given  of  a  stepladder 
falling  across  his  back  a  month  before  the  symptoms  ap- 
peared. A  diagnosis  was  made  of  spinal  caries  and  a  brace 
was  applied.  Ten  days  later  there  was  scarcely  any  resist- 
ance on  the  part  of  the  psoas,  yet  the  spinal  stiffness  re- 
mained the  same. 

Three  years  after  the  above  note  was  made,  the  boy  came 
under  treatment  again  for  a  recurrence  of  the  same  symp- 
toms identically  that  had  presented  at  first,  and  they  were 
now  of  four  days  standing. 

The  mother  was  quite  sure  that  the  boy  had  been  pro- 
nounced cured  shortly  after  the  removal  of  the  brace  in 
1876.  Now  there  co.uld  not  be  found  any  evidences  that 
spinal  caries  had  existed  and  the  case  was  pronounced  one 
of  neurosis  of  the  hip.  A  blister  to  the  lumbar  spine  was 
ordered,  and  in  addition  to  this,  the  fluid  extract  of  ergot 
in  drachm  doses  three  times  a  day.  The  ergot  was  pre- 
scribed a  week  later,  the  blister  not  having  been  followed 
by  prompt  relief.  Three  days  after  the  ergot  treatment  had 
been  instituted,  the  symptoms  subsided,  the  limb  was 
straight  and  he  was  discharged  cured. 

In  March,  1883 — just  four  years  having  elapsed — he  ap- 
peared again,  complaining  of  the  same  group  of  symptoms. 


NEUROSES  OF  THE  HIP.  63 

The  limb  was  advanced,  natis  flattened  a  little,  the  ilio- 
femoral  crease  lower,  while  the  resistance  to  movement 
existed  only  in  the  thigh  flexors. 

The  symptoms  promptly  subsided  under  blistering,  and 
the  boy  was  soon  discharged  again. 

At  no  time  was  there  any  atrophy  of  the  limb,  and  at  no 
time  were  there  any  signs  about  the  hip  save  a  lameness 
and  spasm  of  the  ilio-psoas.  There  was  no  evidence  that 
this  boy  aimed  at  any  mimicry,  and  the  lesion,  if  any  ex- 
isted, was,  I  think,  a  meningeal  hyperaemia  caused  in  the  first 
instance  by  the  direct  blow,  and  the  meninges  being  ren- 
dered thus  vulnerable  were  easily  excited  to  similar  condi- 
tions. The  theory  I  favored  in  my  communication  to  the 
Neurological  Association  was  the  hyperaemic  rather  than 
the  anaemic  one,  but  I  had  no  pathological  facts  at  that  time, 
nor  have  I  any  now. 

The  hysterical  element  is  well  illustrated  in  this  case  re- 
ported by  Dr.  Shaffer.  It  was  that  of  a  girl  aged  ten,  com- 
ing under  his  observation  in  September,  1876.  She  suffered 
from  all  the  important  and  many  of  the  urgent  symptoms 
of  disease  in  the  left  hip.  The  family  history  was  unsatis- 
factorily given.  The  symptoms  had  come  on  very  insidi- 
ously, the  limp  coming  before  the  pain,  though  the  interval 
was  very  short.  Deformity  and  sleepless  nights  had  fol- 
lowed, and  when  Dr.  S.  saw  her  she  was  on  crutches.  The 
symptoms,  I  had  almost  forgotten  to  mention,  followed 
closely  upon  a  fall.  The  doctor  had  great  difficulty  in 
securing  an  examination,  and  it  was  only  after  many  sug- 
gestions that  "  the  patient  was  finally  placed  in  the  supine 
position,  the  mother  in  the  meantime  making  what  seemed 
to  be  manual  traction  with  a  degree  of  force  that  indicated 
long  practice.  The  patient  all  this  time  was  shrieking  with 
pain  and  grasping  the  furniture  near  at  hand,  apparently  as 
a  means  of  counter-traction.  I  imagined  that  the  case  was 
one  of  chronic  ostitis  of  the  hip-joint  in  the  stage  of  ex- 
acerbation. After  much  persuasion,  I  at  last  induced  the 
mother  to  permit  me  to  make  the  traction  and  control  the 
limb.  I  then  commenced  to  gently  test  the  condition  of 
the  joint,  as  regards  motion.  While  manipulating  in  the 
mildest  way  I  was  startled  by  an  urgent  cry  from  the  patient 
and  imperative  command,  'Hold  it  tighter,'  two  or  three 
times  repeated.  I  was  already  making  all  the  traction  pos- 
sible, and  naturally  asked  an  explanation.  The  mother  hur- 
riedly said,  '  You  don't  squeeze  tightly  enough.'  This 


64  DISEASES  OF  THE  HIP. 

threw  a  new  light  on  the  symptoms.  Desisting  wholly  from 
all  efforts  at  traction,  I  merely  compressed  the  ankle-joint 
with  all  my  power.  While  doing  this  I  could  place  the 
thigh  in  any  position,  and  could  even  press  the  articular 
surfaces  together  without  resistance  or  complaint. 

"  Still  '  squeezing  the  ankle,'  I  was  able  to  get  the  patient 
in  the  upright  position  with  little  or  no  trouble.  Without 
any  support  but  that  afforded  by  her  crutches,  the  thigh  be- 
came flexed  and  adducted.  The  whole  limb  was  visibly, 
though  not  markedly,  atrophied.  There  were  various  hy- 
peraesthetic  areas  on  the  affected  limb — principally  on  the 
inner  aspect  of  the  thigh — and  over  the  crest  of  the  ilium. 
Pain  was  produced  by  pressure  through  the  trochanters,  by 
crowding  the  sacro-iliac  surfaces  together,  and  by  digital 
compression  in  the  inguinal  region.  The  patient  stated 
absolutely  that  she  could  not  walk  without  support.  There 
was  normal  faradic  contractility  of  the  leg  and  thigh  mus- 
cles." 

The  doctor  informed  the  mother  that  the  child  did  not 
have  hip-disease,  but  his  opinion  was  not  well  received. 
Some  time  later  he  saw  the  patient  in  his  wards  at  St.  Luke's, 
still  on  crutches,  and  still  with  "  hip-disease."  The  mother 
had  sought  other  advice  and  the  case  pronounced  one  of 
"hip-disease."  Under  treatment  for  the  neurosis  she  soon 
recovered  and  left  the  hospital. 

A  letter  to  Dr.  Shaffer  from  Dr.  G.  A.  Spaulding,  is  so 
interesting  a  sequel  to  the  case  that  I  shall  make  no  apology 
for  quoting  it. 

"On  February  19,  1879,  about  two  months  after  her  dis- 
charge, her  mother  again  presented  the  patient  for  admis- 
sion to  the  hospital,  giving  the  following  history  :  A  few 
weeks  previous  she  had  been  seized  with  convulsions. 
These  convulsions,  the  mother  stated,  were  becoming  more 
and  more  frequent  and  alarming — as  many  as  three  or  four 
occurring  in  twenty-four  hours.  As  the  mother  gave  this 
history,  she  was  occupied  in  unrolling  a  large  bundle,  which 
proved  to  be  a  blanket.  This  she  spread  carefully  upon  the 
floor,  remarking  that  the  hour  for  one  of  these  attacks  had 
arrived,  and  that  it  was  her  custom  to  put  the  blanket  down 
as  a  protection.  Precisely  at  n  o'clock  A.M.  the  patient 
composed  herself  carefully  upon  the  blanket,  and  passed 
into  one  of  the  most  characteristic  hysterical  convulsions  I 
have  ever  witnessed.  The  subsequent  history  is  very  brief 
and  most  satisfactory.  The  usual  remedies  lessened  the 


,  NEUROSES  OF  THE  HIP.  65 

frequency  and  shortened  the  duration  of  the  attacks.  But 
an  absolute  cure  was  not  effected  until  later.  I  chanced  to 
be  in  the  ward  one  day  at  the  time  the  patient  was  seized 
with  a  convulsion,  and  happening  to  see  a  siphon  of  carbonic 
acid  water,  I  picked  it  up  and  holding  the  young  girl  firmly 
by  the  back  hair,  I  discharged  the  contents  of  the  syphon 
down  her  throat.  Her  convulsive  movements  were  instantly 
checked,  and  she  promised  to  avoid  all  such  conduct  in  the 
future.  She  kept  her  word,  and  in  a  few  weeks  was  dis- 
charged from  the  hospital.  During  all  this  time  the  patient 
had  no  recurrence  of  the  hip-joint  manifestations." 

It  has  been  my  experience,  as  it  has  been  also  that  of  other 
observers,  to  find  genuine  cases  of  bone  disease  of  the  hip 
with  hysterical  or  neurotic  symptoms  complicating. 
These  would  be  the  cases  where  one  finds  much  difficulty 
in  differentiating  one  affection  from  the  other.  There  are 
indeed,  very  many  old  cases  of  ankylosis  of  the  hip  from 
suppurative  and  non-suppurative  disease,  presenting  most 
marked  neurotic  phenomena.  In  August,  1877,  a  girl 
twelve  years  of  age  came  under  treatment,  presenting  a 
marked  deformity  of  the  left  hip — two  inches  shortening,  two 
inches  atrophy  of  the  thigh,  one  of  calf,  a  sesile  fluctuating 
tumor  about  the  trochanter  without  tenderness  or  extra  heat 
thereover,  muscular  resistance  to  abduction  and  extension, 
while  flexion  was  easily  made.  Her  dorso-lumbar  spine 
was  excessively  tender  Three  years  antedating  this  ob- 
observation  she  began  to  walk  lame  and  had  pain  three 
months  afterwards.  With  the  invasion  of  pain  she  soon 
was  unable  to  walk,  and  for  four  months  her  sufferings  and 
constitutional  symptoms,  from  the  history  given,  were 
very  great.  A  peculiar  neurosis  would  manifest  itself 
during  the  remissions  of  pain  about  the  hip,  viz.,  a  sensa- 
tion about  head  and  right  ear  as  if  water  were  dripping. 
Eight  months  after  her  first  symptoms  of  joint  disease  she 
took  to  crutches,  and  on  these  she  has  walked  for  over  two 
years,  In  the  family  there  is  a  distinct  neurotic  and  a 
tuberculous  history,  A  blister  to  the  tender  spine  was 
ordered,  and  after  a  "  terrible  drawing"  on  the  part  of  the 
aforesaid  blister,  she  reported  much  improvement  two  weeks 
later.  A  high  shoe  which  she  had  been  wearing  was  dis- 
carded now,  as  the  limb  seemed  to  be  longer,  and  the 
crutches  were  likewise  of  no  further  use. 

Belladonna  in  gradually  increasing  doses  was  ordered. 
The  patient  continued  to  improve,  and  one  morning  about 


66  DISEASES   OF  THE   HIP. 

four  months  after  her  first  visit,  and  after  a  so-called  mala- 
rial attack,  my  attention  was  called  to  a  hypersesthetic  area 
on  the  sole  of  the  foot.  For  this  the  hot- water  douche  was 
advised,  and  relief  promptly  followed,  soon  after  which 
she  passed  from -under  observation.  Curious  to  learn  the 
outcome,  I  traced  out  the  case,  and  found  March  16, 
1883,  that  in  the  five  years  no  neurotic  symptoms  had  been 
present,  that  the  fluctuating  tumor  had  disappeared,  that 
the  disease  about  the  hip  had  been  free  of  any  exacerba- 
tions, and  that  the  result  under  expectant  treatment  was 
certainly  very  good. 

One  of  the  most  difficult  problems  is  the  differentiation 
of  neuralgias  in  and  about  the  hip  from  true  disease  of  the 
joint.  In  these  cases  we  seldom  have  any  reflex  contrac- 
tions about  the  joint.  There  is  the  lameness,  the  pains 
over  bony  prominences,  the  insidious  invasion,  the  exacerba- 
tions, and  the  atrophy.  It  is  safe,  I  think,  then,  to  exclude 
joint  disease  if  the  absence  of  reflex  symptoms  persist,  and 
if  the  family  history  be  predominently  neurotic.  Many  and 
many  a  case  have  I  seen  wherein  the  family  history  alone 
was  sufficiently  neurotic  to  enable  me  to  reach  a  conclusion. 

One  of  the  most  interesting  cases — in  view  of  its  neurotic 
phases — that  I  have  had  the  opportunity  of  observing,  was  in 
the  person  of  a  girl  aged  twelve,  who  came  to  me  in  1876. 
A  younger  sister  had  died  of  tubercular  meningitis,  a 
brother  aged  nine  subsequently  came  under  treatment  for 
talipes  equinus  depending  on  infantile  paralysis,  and  an 
elder  sister  I  have  likewise  had  under  treatment  for  lateral 
curvature^associated  with  an  anterior  crural  neuralgia. 

The  girl  herself  came  with  a  history  of  lameness  "  off  and 
on"  for  two  years,  and  unassociated,  so  far  as  I  could  learn, 
with  any  fall  or  injury.  She  simply  began  to  feel  tired 
and  to  favor  the  right  limb.  The  natis  on  this  side  was 
flattened,  the  crease  was  shortened,  there  was  one  inch 
atrophy  of  the  thigh,  and  three-quarters  of  the  calf.  The 
joint-movements  were  absolutely  faultless.  A  diagnosis, 
however,  was  made  of  "  morbus  coxae,"  and  she  was  ad- 
mitted to  hospital. 

Under  expectant  treatment  she  was  soon  so  far  relieved 
that  she  was  discharged.  The  pain  and  lameness  had  en- 
tirely disappeared.  The  symptoms  returned  in  a  month, 
and  a  blister  was  ordered.  Very  soon  afterwards — ten  days 
— she  was  entirely  relieved.  The  subsequent  notes  are  full 
of  relapses,  and  finally  a  chorea  developed  in  1880,  yielding 


NEUROSES   OF  THE  HIP.  6/ 

to  arsenical  treatment  in  about  three  weeks.  In  January, 
1881,  she  developed  an  acute  articular  rheumatism  affecting 
both  knees  and  the  left  ankle.  This  took  the  usual  course. 
Chorea  minor  developed  a  year  afterwards.  Last  summer 
— 1882 — she  had  a  sciatica.  She  frequently  has  precordial 
pains  without  any  heart  lesion.  Her  general  health  is  ap- 
parently good  all  the  while.  The  lameness  has  not  re- 
curred, and  yet  the  thigh  is  two  inches  smaller  than  its 
fellow.  The  temptation  to  regard  these  phenomena 
malarial  by  reason  of  the  fact  that  certain  heart  symp- 
toms yield  frequently  to  quinine,  has  led  me  to  employ 
that  drug  from  time  to  time  in  toxic  doses  without 
material  benefit.  At  present  the  actual  cautery  is  being 
employed. 

The  diagnosis  furthermore  is  obscured  by  certain  inflam- 
matory signs  seen  in  the  distribution  of  nerves  about  the 
gluteal  region,  and  really  it  is  very  difficult  to  avoid  com- 
mitting an  error.  In  some  instances  there  is  distinct  swel- 
ing  about  the  hip,  and  this,  associated  with  the  characteristic 
deformity  and  muscular  contraction  causes  one  to  hesitate 
long  before  making  a  diagnosis.  This  became  necessary  in 
the  following  case,  which  has  been  reported  to  me  during  the 
past  year,  as  continuing  well  and  free  from  lameness.  The 
girl,  a  strumous-looking  child,  aged  ten  years,  was  admitted 
to  hospital  in  April,  1876.  The  family  history  is  imper- 
fectly obtained,  as  no  other  members  are  present  at  date  of 
admission,  the  child  coming  from  an  orphan  asylum.  A 
history  of  the  exanthemata  is  obtained,  however,  and  of  a 
fall  from  a  bed  six  or  eight  weeks  prior  to  this  date,  and  the 
appearance  of  signs  pointing  to  some  lesion  about  the  hip 
two  weeks  thereafter.  This,  taken  in  connection  with  her 
general  appearance,  a  marked  lameness  typical  of  chronic 
bone-disease  of  the  hip,  the  position  of  the  right  limb  in 
standing,  viz.:  semiflexion,  eversion,  and  rotation  outward; 
a  flattening  of  the  nates,  tenderness  on  pressure  thereabout 
amounting  to  a  hyperaesthesia;  resistance  to  flexion  beyond 
90°,  to  extension  beyond  160°;  a  swelling  near  the  crest  of 
the  ilium;  an  absence  of  real  shortening,  while  there  is  an 
apparent  shortening — the  above  history,  I  say,  taken  in  con- 
nection with  all  these  signs,  positive  and  negative,  leads  to 
a  diagnosis  of  "  hip-disease"  second  stage  ;  though,  on  re- 
flection, it  occurs  to  us  that  such  an  amount  of  hyperaesthesia 
cannot  be  due  to  disease  in  the  hip-joint,  and  that  such 
deformity  has  come  on  too  soon  for  true  bone  disease,  and 


68  DISEASES  OF  THE   HIP. 

hence  we  placed  an  interrogation  point  after  the  diagnosis 
already  recorded.  The  treatment  is  expectant. 

On  the  9th  May  a  distinct  and  well-marked  fulness  over 
crest  of  right  ilium  was  observed, extending  from  the  anterior 
superior  spinous  process  to  the  sacro-iliac  junction,  quite 
tender  to  pressure.  The  hip-joint  seems  ree  of  any  disease. 

The  fulness  slowly  increasing,  a  fly  blister  is  applied  the 
evening  of  the  twelfth,  the  usual  poulticing  to  follow. 

Abed  the  forenoon  of  the  i6th,  but  in  the  afternoon  she 
moves  about  the  ward  with  great  difficulty  by  aid  of  a  chair, 
the  foot  being  raised  some  two  inches  from  the  floor.  The 
symptoms  gradually  subsided,  and  with  the  exception  of  a 
pain  in  the  lumbar  region  at  times,  nothing  occurred  until 
the  middle  of  August,  when  the  fulness  seemed  to  have 
shifted  from  the  ilium  to  the  thigh,  and  the  upper  fourth  of 
this  member  measured  one  inch  more  in  circumference  than 
the  left.  There  were  also  heat  tenderness  and  constitutional 
disturbance  generally.  A  cathartic,  evaporating  lotion,  and 
rest  seemed  to  afford  relief  in  a  fortnight,  though  the  ful- 
ness remained.  With  a  few  intervening  notes  of  minor  im- 
portance, it  is  noted  a  month  later  that  the  child  stands 
with  both  limbs  parallel,  and  scarcely  a  limp  can  be  detected 
in  her  gait.  The  changes  subsequent  to  this  depended  on 
the  amount  of  exercise,  and  the  treatment  was  purely  ex- 
pectant. At  times,  she  was  in  great  pain,  unable  to  leave 
her  bed,  and  the  parts  around  the  hip  would  become  exquis- 
itely sensitive,  then  relief  would  come  and  she  would  get 
almost  well. 

In  one  of  these  attacks,  in  May,  1877,  there  was  discovered 
marked  tenderness  over  and  to  either  side  of  the  spinous  pro- 
cesses from  the  fifth  dorsal  vertebra  to  the  sacrum.  The 
spine  was  thoroughly  blistered  and  poulticed,  with  decided 
benefit.  Subsequently,  ergot  was  administered,  and  by 
July  2oth  there  was  no  pain  or  lameness  or  other  sign 
of  disease.  She  was  kept  under  daily  observation  until 
October  5th,  up  to  which  time  not  an  untoward  symptom 
had  recurred,  and  she  was  discharged  cured;  no  muscular 
rigidity,  no  tenderness — spinal  or  femoral — and  no  lame- 
ness whatever  existing. 

To  sum  up,  then,  the  points  in  diagnosis: 

There  will  in  nearly  every  instance  be  a  neurotic  element 
in  the  family  history.  The  history  is  all  important,  and  in 
certain  cases  may  furnish  evidence  which  will  be  pathog- 
nomic. 


NEUROSES   OF  THE   HIP.  69 

In  neuromimesis  certain  tricks  will  sooner  or  later  be 
discovered  on  examination,  which,  it  is  needless  to  say, 
should  in  all  cases  be  most  thoroughly  made.  The  psychi- 
cal element  will  predominate  in  this  as  in  the  hysterical 
joints.  The  absence  of  atrophy  both  in  neuromimesis  and 
hysteria,  with  electrical  reactions  to  faradism  preserved,  the 
hyperaesthetic  areas  and  occasionally  paraesthetic  areas 
will  contribute  largely  to  the  exclusion  of  joint-disease. 
There  is  a  peculiarity  of  the  gait  that  is  indicative  of  pain 
or  fear,  and  that  is  otherwise  difficult  to  describe.  If  con- 
tractions exist  other  signs  that  will  invalidate  them  as 
signs  in  joint-disease  will  surely  be  present  and  their  sig- 
nificance will  be  manifest. 

Again,  the  age  will,  as  a  rule,  be  between  ten  and  twenty. 
Many  of  the  phenomena  are  absent  about  the  beginning 
of  menstruation.  In  neuralgia  as  before  mentioned  the 
history  will  help  one  to  estimate  the  value  of  the  atrophy, 
and  the  freedom  from  muscular  resistance  is  significant. 

Spinal  tenderness,  though  not  invariably  present,  is  a  very 
strong  diagnostic  point  and  this  will  be  worthy  of  study. 

The  treatment  is  simple  in  those  cases  of  muscular  con- 
traction, especially  if  the  tender  spine  be  present.  Counter- 
irritation  in  the  form  of  blistering,  the  actual  cautery,  or 
simpler  means,  such  as  liniments,  and  the  administration  of 
ergot  or  belladonna. 

In  cases  of  hysterical  contraction  or  of  neuromimesis 
the  treatment  by  fly-blisters  in  connection  with  moral 
suasion  secures  good  results.  The  great  benefit,  in  many 
instances,  is  in  the  revulsive  effect  'of  the  blister,  while  in 
some  cases  the  subsequent  poulticing  gives  to  the  blister  a 
derivative  effect.  Prompt  relief  very  often  follows  and  the 
recurrences  are  as  promptly  relieved.  Take  the  following 
as  illustrative  of  the  relief  afforded  by  blistering. 

A  girl,  aged  nineteen,  was  admitted  to  the  hospital  in 
June,  1880.  She  came  from  one  of  the  towns  on  the 
Hudson,  and  was  on  crutches  when  she  appeared  for  treat- 
ment. The  family  history  could  not  be  obtained;  the  pa- 
tioned  reported  that  as  a  child  she  was  delicate,  but  had 
been  in  fair  health  up  to  January,  1880,  when  she  had  a  fall, 
•which  was  soon  followed  by  great  pain  in  the  knee.  This 
shifted  to  the  hip  two  weeks  later,  and  she  walked  lame, 
suffering  much  from  fatigue.  For  the  past  six  weeks  she 
has  not  been  able  to  walk  unless  with  crutches.  She  has 
been  very  restless  nights,  and  has  lost  flesh. 


70  DISEASES   OF  THE   HIP. 

She  stands  resting  all  of  her  weight  on  the  right  limb' 
the  left  foot  not  even  touching  the  floor.  The  left  limb  is 
advanced  and  rotated  outward,  while  the  pelvis  is  tilted  to 
this  side.  No  infiltration  about  the  joint;  thighs  equal  in 
size.  The  pain  is  referred  to  the  left  loin,  the  spine,  and 
anterior  surface  of  the  knee.  Absence  of  joint-tenderness, 
but  muscular  tenderness,  with  pain  on  pressure  along  sciatic 
nerve.  The  thigh  can  be  almost  completely  flexed  without 
pain  or  resistance.  Indeed  all  the  movements  are  normal, 
save  extension,  which  aggravates  the  pain.  There  is  for- 
mication about  the  sole  and  ankle  and  a  moderate  degree 
of  dorso-lumbar  tenderness. 

Joint-disease  was  excluded  in  the  diagnosis,  and  a  fly- 
blister  was  applied  to  the  spine  the  same  night.  There 
was  a  little  relief  after  two  or  three  days,  but  nothing  very 
marked  until  the  morning  of  July  the  2d — ten  days 
after  admission — when  she  got  up  from  a  rolling-chair  and 
walked  across  the  floor  with  very  little  lameness  and  very 
little  exertion.  The  pain  had  completely  subsided  and  the 
deformity  no  longer  existed.  She  was  then  put  upon  cod- 
liver-oil  and  an  iron  mixture. 

By  the  ist  of  August  all  signs  of  disease  had  disappeared, 
and  a  month  later  she  was  discharged.  No  signs  present, 
and  general  health  excellent.  She  continued  free  from 
lameness  or  any  symptoms  until  about  two  or  three  months 
ago.  She  had  become  a  little  anaemic,  and  complained  of 
pain  about  her  hip  again.  She  came  to  the  hospital,  had 
similar  treatment,  and  returned  to  her  home  in  two  or  three 
weeks  fully  restored.  She  had,  in  fact,  no  joint-symptoms 
at  this  last  visit. 

And  again,  the  following  case,  in  a  girl  aged  nine  and  a 
half,  a  robust,  hearty-looking,  child,  who  was  admitted  in 
the  spring  of  1877.  Until  eighteen  months  before,  her 
health  had  been  excellent,  and  the  family  histories  on  both 
sides  represented  as  good,  although  during  the  past  year 
a  sister  has  been  under  treatment  for  infantile  paralysis. 
The  patient  however,  after  a  fall,  one  and  a  half  years  since, 
experienced  a  sense  of  weakness  in  right  lower  extremity, 
with  pain  in  knee.  This  continued  for  three  or  four  months, 
uncomplicated  with  any  other  functional  disturbance.  She 
has  walked  lame,  and  during  the  past  three  months  the 
symptoms  have  been  increasing  in  severity.  On  admission, 
a  thorough  examination  detects  only  a  marked  halt  in  her 
gait,  a  lengthening  of  the  right  natal  fold,  slight  infiltration 


NEUROSES   OF  THE  HIP.  71 

of  the  right  inguinal  ganglia,  a  furuncle  in  acumination, 
below  the  right  patella  (sufficient  to  account  for  condition 
of  the  inguinal  ganglia),  and  a  slight,  though  decided  ten- 
derness on  pressure  over  the  spinous  processess  of  the  eighth, 
ninth,  and  tenth  dorsal  vertebrae.  The  negative  points 
were  all  noted  in  the  case-book,  and  transcription  here  is 
unnecessary. 

A  blister  was  applied  to  spine,  and  next  day,  poultices  to 
the  vesicated  surface,  while  at  the  same  time  the  furuncle 
was  subjected  to  appropriate  treatment. 

Ten  days  after  admission,  there  was  no  spinal  tender- 
ness; inguinal  enlargement  was  scarcely  perceptible;  fur- 
uncle has  diappeared. 

Five  days  later  she  was  discharged,  cured,  and  returned 
to  her  home. 

Recent  opportunity  has  presented  for  learning  the  final 
result  in  this  case,  and  I  find  that  she  has  never  had  any 
relapse. 

The  belladonna  treatment,  in  my  opinion,  is  certainly  to  be 
recommended  as  I  have  witnessed  some  remarkably  good 
results  from  its  administration.  Ergot  holds  a  place  therea- 
peutically  of  somewhat  questionable  value  and  may  serve  a 
good  end  in  properly  selected  cases.  Above  all,  attention 
to  the  minor  details  of  general  health,  cathartics  judiciously 
employed,  tonics  and  nutrients,  changes  of  living,  and  rest 
are  agents  that  the  successful  practitioner  cannot  afford  to 
overlook.  Concerning  electricity  I  have  had  no  experience, 
and  a  priori  should  consider  it  contra-indicated  except  in 
the  neuralgia  which  comes  under  this  classification. 

It  is  my  conviction  that  many  of  these  neuroses  depend 
on  meningeal  hypercemia  induced  by  malarial  poisoning. 
I  have  a  patient  at  present,  a  patient  whom  I  see  once  in 
two  or  three  months:  he  lives  beyond  the  Harlem  River,  in 
a  district  notoriously  malarial.  Is  ten  years  of  age,  a  male, 
and  is  of  a  neurotic  diathesis.  I  first  saw  him  March 
nth,  1882.  He  had  been  screaming  at  night  for  a  long 
time;  had  been  favoring  the  right  hip  in  walking  for  six  or 
eight  months,  yet  the  limp  was  not  constant;  and  he  com- 
plained of  pain  in  the  course  of  the  anterior  crural.  The 
night  screamings,  I  learned,  on  further  investigation,  were 
what  the  mother  called  ".night  terrors,"  and  he  had  been 
subject  to  these  phenomena  for  many  years.  He  did  not 
have  the  ostitic  cry.  The  anterior  crural  pain  was  not 
constant,  was  not  periodical,  sometimes  it  was  present  in  the 


72  DISEASES   OF  THE  HIP. 

morning,  sometimes  in  the  evening.  They  were  unin- 
fluenced by  change  in  the  weather.  I  searched  diligently  for 
the  usual  symptoms  of  malarial  poisoning  with  negative 
results.  During  the  last  summer  he  had  a  diarrhoea  the 
course  of  which  was  marked  by  intermission.  He  now  suf- 
fered from  constipation.  I  could  not  detect  any  atrophy  of 
the  limb,  and  did  not  encounter  any  muscular  resistance  in 
testing  the  functions  of  the  joint.  There  was  no  joint-ten- 
derness. 

On  general  principles  I  ordered  five  grains  of  quinine 
twice  a  day,  and  on  the  twentieth,  nine  days  elapsing,  he 
called  to  report.  The  report  was  that  his  pain  and  lame- 
ness disappeared  within  a  day  or  two,  and  that  he  had 
been  entirely  well  until  the  nineteenth,  when,  after  a  con- 
siderable running  at  play,  he  came  in  very  lame  and  had 
much  pain  in  the  outer  side  of  the  thigh.  His  sleep  during 
the  night,  however,  was  undisturbed,  and  in  the  morning 
he  was  "  all  right  again."  I  still  found  the  joint  functions 
normal.  The  mother,  in  response  to  inquiries,  admitted 
that  a  sewer-pipe  near  her  house  was  open.  The  quinine 
was  continued  in  the  same  doses,  and  on  April  26th  I  ex- 
amined the  boy  again,  to  find  nothing  whatever  in  the  way 
of  sign  or  symptoms.  The  quinine  had  been  continued 
two  weeks  after  the  date  of  the  last  visit,  and  there  being 
no  further  indications  for  its  use  the  mother  had  discon- 
tinued it  of  her  own  accord. 

The  patient  was  conditionally  discharged,  and  on  May 
9th  he  called  again  complaining  of  a  sharp  attack  of  pain 
the  day  before,  during  damp  weather.  There  was  also  this 
morning  a  little  stiffness  at  the  joint,  as  he  had  considera- 
ble difficulty  in  getting  the  stocking  on.  Still  no  joint 
resistance.  The  quinine  was  ordered  again,  and  the  mother 
was  instructed  to  renew  it  on  the  recurrence  of  symptoms. 
From  this  time  to  February  20,  1883,  he  had  one  light 
attack  of  pain,  which  soon  passed  off. 

Then,  again,  there  are  cases  of  neuralgia,  wherein  both 
hips  seem  weak  and  the  limbs  unsteady.  The  first  symp- 
toms here,  perhaps,  begin  years  before  in  the  wake  of  an 
intermittent  fever.  A  condition  of  chronic  malarial  poison- 
ing is  present,  and  quinine  will  not  meet  the  case.  Arsenic 
in  some  of  its  preparations  better  fulfills  the  requirements. 

I  have  seen  speedy  relief  follow  the  use  of  the  cautery  in 
contractions  of  the  ham-string  muscles.  For  instance,  I 
have  applied  it  in  light  strokes  to  the  lumbar  spine  in  a 


NEUROSES  OF  THE  HIP.  73 

Case  where  the  contraction  had  existed  for  six  weeks,  to 
find  entire  relief  the  following  day. 

The  prognosis  is  good  in  the  contractions  accompanied 
by  spinal  tenderness.  This  predicate  I  employ,  however, 
when  the  nature  of  the  affection  is  fully  appreciated.  The 
proneness  to  recur  under  like  causal  conditions  is  certainly 
well  established.  In  the  neuromimetic  forms  the  prognosis 
is  not  so  good.  The  symptoms  may  continue  indefi- 
nitely. Sooner  or  later,  however,  some  one  makes  a 
correct  diagnosis  and  the  case  speedily  terminates  in 
recovery,  or  in  other  neuroses.  The  same  difficulty  is  met 
with  in  the  hysterical  cases;  and  in  the  neuralgic  symptoms 
may  come  and  go  for  years. 


CHAPTER  V. 

I.  RHEUMATISM  OF  THE  HIP. — II.  RHEUMATIC  ARTHRITIS  IN 
THE  ADULT  [MALUM  Cox,*  SENILE]. 

I. 

One  of  the  most  common  errors  with  which  the  general 
practitioner  is  charged  is  that  of  calling  hip-disease  (chronic 
ostitis  of  the  hip)  "rheumatism."  Scarcely  a  week  passes 
but  that  a  patient  suffering  from  the  disease  well  advanced 
is  brought  to  the  dispensary,  the  parents  asserting,  "  my 
doctor  said  it  was  'rheumatism.' "  It  is  seldom  that  a  case 
of  disease  at  the  hip  is  reported  in  extenso,  without  this 
testimony  of  the  friends  is  inserted.  I  have  always  taken 
the  evidence  with  much  allowance,  and  in  many  instances 
I  have  felt  no  disposition  to  censure  the  gentleman  who 
has  made  such  a  diagnosis.  The  invasion  of  this  dreaded 
disease  is  often  very  like  that  of  acute  monarticular  rheu- 
matism, and  for  several  days  and  weeks  even  the  symptoms 
run  along  almost  parallel  one  with  the  other.  I  have  very 
little  doubt  but  that  the  surgeon  who  prides  himself  on  his 
diagnostic  skill  occasionally  commits  just  as  great  an  error 
(considered  as  an  error)  in  calling  cases  of  rheumatism 
"  hip-disease."  I  have  now  the  history  of  a  case  spread 
out  upon  my  books,  in  a  male  child  two  years  of  age,  whose 
symptoms  began  with  sharp  pain  in  the  left  thigh  one  night 
at  eleven  o'clock,  causing  loud  cries,  and  next  day  there 
was  decided  redness  with  a  little  swelling  on  the  upper 
third  of  the  leg,  same  side.  This  child  was  treated,  so  I  am 
credibly  informed,  with  weight  and  pullyfor  "hip-disease." 
When  I  saw  the  patient  one  month  after  the  invasion  of 
the  disease  there  was  effusion  in  with  extra  heat  and  ten- 
derness about  both  ankles  and  the  left  knee.  The  symptoms 
were  subacute  in  character.  The  mother  was  herself  typi- 
cally rheumatic.  Under  soda  salicylate,  vigorously  em- 
ployed, the  symptoms  soon  subsided,  and  in  a  week  he  was 
walking  quite  easily.  A  few  days  latter  I  succeeded,  for 
the  first  time,  in  making  a  thorough  examination  of  the 


RHEUMATISM   OF  THE  HIP.  75 

hip,  finding  absolutely  no  impairment  of  function  and  no 
tenderness  whatever.  Even  after  all  these  changes  for  the 
better,  the  physician  first  in  charge,  the  father  reported, 
called  in,  examined  again,  and  was  willing  to  make  affi- 
davit that  the  case  was  one  of  "hip-disease." 

We  have  been  educated  up  to  a  positive  fear  of  making  a 
diagnosis  of  rheumatism,  especially  muscular  rheumatism. 
One  dreads  criticism,  as  do  some  malariaphobists.  In 
some  localities  it  requires  much  nerve  to  call  a  disease 
malaria.  Those  wiseacres  who  love  to  talk  learnedly 
about  subacute  gastritis,  perisplenitis,  etc.,  lie  in  wait  for 
the  malarial  man.  Now  I  am  pretty  firmly  convinced  that 
many  cases  are  correctly  diagnosticated  rheumatism  out- 
side of  the  large  cities,  and  that  good  results  follow.  It 
has  been  my  privilege  as  a  specialist  to  come  in  contact 
with  many  rheumatic  cases,  and  I  have  recorded  a  few  that 
I  shall  refer  to  in  this  chapter. 

The  term  rheumatism,  as  applied  to  the  muscles,  is  depre- 
cated by  some  authorities.  They  prefer  to  speak  of 
myalgia.  Myalgia  simply  means  pain  in  a  muscle,  and 
nothing  more.  Rheumatism  carries  with  it  not  only  pain, 
but  pain  on  movement,  tenderness,  and  a  rise  of  tempera- 
ture, frequently  associated  with  other  constitutional 
disturbances.  It  does  not  necessary  mean  a  palpable 
myositis,  as  some  clinicians  would  seem  to  intimate. 

Dr.  Garrod,  in  Reynolds'  System  of  Medicine,  defines 
muscular  rheumatism  as  "an  affection  of  the  voluntary 
muscles,  of  an  inflammatory  nature  (?),  but  unaccompanied 
with  swelling,  heat,  redness,  or  febrile  disturbance." 

On  October  1 1,  1878,  a  medical  friend  asked  me  to  see  his 
little  daughter,  two  years  of  age,  in  whom  the  mother  had 
observed,  on  the  2nd,  a  manifest  indisposition.  The  rectal 
temperature  was  103°.  The  day  previous  the  child  had 
eaten  grapes  and  had  swallowed  the  pits.  A  cathartic  was 
administered  immediately  thereafter,  and  the  pits  were 
passed,  per  rectum,  the  next  evening  (the  2nd).  All  day 
the  little  patient  complained  of  pain  about  the  shoulder 
and  in  the  arm,  was  restless  the  next  night,  her  tempera- 
ture that  day  ranging  from  102°  to  103°.  On  the  4th  the 
symptoms  had  subsided,  and  she  was  well  on  the  5th. 
There  was  no  lameness  of  any  kind. 

On  the  morning  of  the  6th,  while  the  mother  was  dressing 
the  child  it  complained  of  pain  in  the  left  thigh  and  in  the 
left  foot,  crying  if  handled  much,  and  was  noticed  walking  a 


76  DISEASES  OF  THE  HIP. 

little  lame — just  a  mere  halt  it  was.  This  lameness  con- 
tinued without  change  one  way  or  the  other  during  the 
7th,  the  8th,  and  the  pth,  and  during  the  night  any  turning 
in  the  crib  would  be  accompanied  by  moaning  and  crying 
aloud.  There  was  no  pain  at  this  time  in  the  arm  or 
shoulder.  Whenever  any  one  grasps  the  hip  in  lifting 
her  an  outcry  is  made.  The  father  I  knew  to  be  a  sufferer 
from  occasional  attacks  of  muscular  rheumatism,  and  he 
regarded  himself  as  a  typical  rheumatic.  On  my  examina- 
tion I  found  the  child  walking  with  a  decided  limp,  more 
correctly  described  as  a  halt.  She  stood  on  the  limb  with- 
out any  evident  tenderness,  and  there  was  nothing  abnor- 
mal in  the  position.  The  nates  were  unchanged,  and  there 
was  no  muscular  spasm  or  resistance  of  any  kind  when  I 
executed  with  the  thigh  the  various  movements  of  the  hip. 
The  joint  was  not  tender  by  any  test  employed;  there  wa? 
no  atrophy,  no  swelling  or  induration  at  any  point,  and  no 
spinal  sign  or  symptoms  could  be  disvovered. 

Four  days  later,  in  the  evening,  I  made  an  examination 
with  the  same  care,  and  the  lameness,  as  on  the  first  exam- 
ination, was  absolutely  the  only  sign  I  could  discover.  It 
occurred  to  me  at  this  date  that  this  lameness  partook 
more  of  the  nature  of  that  due  to  paresis  of  the  anterior 
tibials,  yet  I  could  not  appreciate  any  atrophy.  I  learn  that 
in  the  morning  when  the  child  is  set  upon  the  chamber-pot 
it  complains  of  pain  in  the  left  hip,  and  raises  this  side  of 
the  nates  from  the  vessel.  I  had  scarcely  ventured  on  a 
diagnosis  up  to  this  time,  but  was  gradually  eliminating 
bone  or  joint  disease.  A  day  or  so  later  I  employed  the  far- 
adic  current  diagnostically  and  the  result  was  negative. 
The  lameness  and  morning  tenderness  continued,  gradually 
growing  less,  however,  until  the  28th,  when  all  disappeared, 
and  the  case  was  discharged  cured.  There  has  been  no  re- 
currence of  symptoms,  however  light,  up  to  the  present 
date. 

It  will  be  seen  then  that  the  occurrence  of  pain  in  a  fleshy 
part  preceding  lameness,  tenderness,  or  pressure  over  the 
muscles,  constitutional  disturbance  more  or  less  marked, 
and  a  family  history  in  which  rheumatism  is  present,  con- 
stitute the  chief  symptoms  by  which  one  is  to  be  guided. 
Then  the  perfect  freedom  of  joint  movements,  together  with 
a  limp  which  is  suggestive  of  loss  of  power  rather  than  the 
stiffish  limp  of  chronic  ostitis,  known  to  all  orthopedists  as 
the  "hip-limp,"  these  two  signs  are  quite  significant.  A 


RHEUMATISM   OF  THE  HIP.  77 

curious  case,  which  puzzled  not  only  myself  but  several 
other  gentlemen  to  whose  diagnostic  skill  I  always  pay 
humble  tribute,  came  under  my  observation  in  1875,  and  I 
was  unable  to  venture  a  diagnosis  even  until  1878,  in  Octo- 
ber, when  an  attack  came  on  which  acted  so  much  like  an 
acute  or  subacute  muscular  rheumatism.  The  case  in  1875 
was  this: 

A  female  child,  two  and  one  third  years  of  age,  living  in 
a  malarial  locality,  and  the  daughter  of  a  gentleman  who 
combines  the  rheumatic  and  the  strumous  diatheses,  with 
the  rheumatic  notably  preponderating,  was  taken  in  Octo- 
ber of  that  year  with  pain  near  the  left  hip,  chiefly  confined 
to  the  gluteal  region.  Lameness  came  on  simultaneously. 
There  was  no  evidence  of  any  tramuatism  in  the  case.  At 
times  there  was  stiffness  of  the  lower  portion  of  the  spine 
and  tenderness  about  the  crest  of  the  ilium,  suggesting  to 
one  expert  a  low  vertebral  ostitis.  Another  inclined  to  os- 
titis  of  the  hip,  although  neither  he  nor  any  one  of  us  could 
find  any  muscular  resistance  about  this  joint.  The  child  was 
lame,  however,  for  nearly  five  months,  some  days  less,  some 
days  more,  some  days  not  at  all.  There  was  no  scream- 
ing or  restlessness  during  sleep,  and,  indeed,  there  never 
was  any  pain  that  could  be  regarded  as  at  all  signifi- 
cant. The  hip  was  blistered,  moderate  rest  was  maintained, 
and  finally,  just  as  I  was  coming  to  believe  in  an  iliac  perios- 
titis, all  symptoms  subsided  and  the  child  was  well. 

It  so  continued  until  the  second  attack,  which  I  studied 
more  closely,  and  which  was  easier  of  diagnosis. 

In  October,  1878,  on  the  morning  of  the  i7th,  without 
any  premonitory  symptoms,  the  child  cried  on  getting  out 
of  bed  and  could  with  difficulty  be  dressed,  so  great  was  the 
hyperaesthesia  about  the  hips.  She  was  unable  to  walk, 
and  was  carefully  carried  down  stairs.  Remained  sitting 
all  day,  unless  she  wanted  anything  not  within  reach;  then 
she  would  hobble  along  by  the  aid  of  a  cane,  the  left  thigh 
being  held  all  the  while  in  flexion,  so  that  the  foot  would 
touch  the  floor  only  by  the  ball  and  toes.  If  anyone  moved 
her  she  cried.  The  weather  on  the  i6th — the  day  preceding 
the  attack — changed  from  warm  to  cold,  and  it  rained  that 
night. 

On  the  evening  of  the  i7th  she  seemed  better,  but  was 
unable  to  walk  upstairs,  and  cried  this  night  five  or  six 
times  while  asleep.  There  was  nothing  to  indicate  to  the 
father  any  febrile  condition.  She  had  to  be  carried  down 


?8  DISEASES   OF  THE  HIP. 

stairs  on  the  morning  of  the  i8th,  and  used  the  walking- 
stick  in  going  about  the  floor.  About  the  middle  of  the  af- 
ternoon of  this  day  I  called  to  examine  the  patient .  and 
learned  that  she  was  playing  in  the  yard.  I  could  find  only 
a  trace  of  lameness,  no  swelling  about  the  joint,  no  rise  of 
temperature,  and  no  resistance  to  any  of  the  movements  of 
the  hip  carried  to  the  normal  extent.  She  had  not  taken 
any  medicine.  Next  day  she  went  to  school,  and  has  re- 
mained well  and  free  from  lameness  to  the  ist  of  July,  1883, 
when  she  came  in  from  school  crying  and  complaining  of 
pain  in  the  left  knee.  In  an  hour  all  pain  had  subsided. 

Again,  on  the  evening  of  the  i2th  of  August  she  was 
quite  lame  and  suffered  much  from  pain  about  the  same  knee. 
She  could  not  get  up  stairs  without  assistance.  All  day 
long  she  played  without  any  lameness  or  pain  and  seemed 
to  be  in  excellent  health.  There  was  no  restlessness  or  dis- 
turbance of  any  kind  during  the  night,  and  by  the  morning 
all  signs  and  symptoms  had  vanished. 

Now  whether  the  attack  in  1875  was  one  of  subacute 
muscular  rheumatism,  or  not,  I  am  not  in  a  position  to  de- 
cide, yet  my  belief  in  that  theory  is  very  strong.  The 
strumous  diathesis  which  in  her  case  was,  and  is  now,  so 
well  marked,  stands  in  the  way  of  my  accepting  any  theory 
as  to  bone  or  joint-disease  undergoing  resolution.  The 
parts  must  be  without  swelling,  and  yet  the  swelling  may 
not  be  present  when  the  examination  is  made.  But  for  a  clear 
history  of  this  sign,  and  an  uncertain  history  of  a  blow,  I 
might  have  diagnosticated  rheumatism  in  a  boy  aged  nine, 
who  came  under  observation  in  April,  1881.  The  family  his- 
tory was  exceptionally  good,  and  he  had  been  complaining 
only  eleven  days  when  he  entered  the  hospital.  The  first 
symptom  was  pain  referred  to  the  left  gluteal  region,  and 
this  was  on  the  pth.  It  followed  a  kick  on  the  hip  by  a 
playfellow,  the  boy  reported.  His  sleep  was  disturbed  by 
pain  the  same  night,  but  he  did  not  walk  lame  until  the 
nth,  when  he  had  a  chill,  which  was  followed  immediately 
by  fever,  and  the  next  day  there  was  swelling  over  the  hip. 
He  was  treated,  as  report  went,  for  rheumatic  fever,  being 
confined  to  his  bed  because  of  his  inability  to  walk.  Fin- 
ally he  was  sent  to  the  hospital  for  supposed  "hip-disease." 
On  examination  he  was  totally  unable  to  walk,  and  it  re- 
quired considerable  effort  on  his  part  to  stand.  The  spine 
was  normal,  and  there  was  no  infiltration  or  swelling  about 
the  hip.  Flexion  and  extension,  when  carried  to  extremes, 


RHEUMATISM  OF  THE  HIP.  79 

gave  him  pain.  The  left  natis  was  flattened  and  the  gluteal 
crease  obliterated.  As  he  lay,  in  the  dorsal  decubitus  the 
thigh  was  flexed  and  adducted  to  a  slight  degree.  Under 
expectant  treatment  he  soon  recovered,  and  was  ready  for 
discharge  six  weeks  after  admission.  The  slight  resistance 
to  movements,  the  position  of  the  limb,  the  chill  and  fever 
followed  so  closely  by  the  swelling,  which  the  parents  re- 
membered and  described  so  well,  and  the  present  recovery, 
pointed  to  a  traumatic  cellutitis,  which  underwent  resolu- 
tion. 

To  diagnosticate,  then,  a  muscular  rheumatism  in  the 
vicinity  of  the  hip,  the  following  points  are  necessary  if  it 
occurs  in  a  young  child  : 

1.  A  rheumatic  history  in  one  or  the  other  of  the  parents. 

2.  A  sudden  invasion,  the  first  symptom  being  pain. 

3.  Muscular  hyperaesthesia  more  or  less  pronounced. 

4.  Absence  of  deformity. 

5.  Absence  of  resistance  to  normal  joint  movements.     In 
older  children  it  seldom  occurs,  and  in  adults  it  sometimes 
occurs,  but  then  it  is  more  apt  to  be  confounded  with  sci- 
atica and  to  be  associated  with  a  lumbago.     Difficulties  in 
diagnosis  will  therefore  seldom  occur  in  adult  life. 

In  the  rheumatism  which  affects  the  immediate  periar- 
ticular  structures  it  so  seldom  affects  this  joint  alone  that 
one  will  have  little  or  no  occasion  for  differential  diag- 
nosis. 

In  youth,  however,  and  in  adult  life  we  occasionally  have 
articular  rheumatism,  affecting  this  joint,  and  the  symptoms 
differ  little  from  those  of  ordinary  polyarticular  rheuma- 
tism. In  the  subacute  and  chronic  forms,  it  becomes  diffi- 
cult in  certain  stages  of  the  disease  to  distinguish  between 
this  and  scrofulous  arthritis. 

In  May,  1880,  I  saw,  with  Dr.  M.  T.  Scott,  in  Lexington, 
Ky.,  a  case  of  joint  disease  in  a  girl  fifteen  years  of  age. 
There  was  the  shortening,  and  the  atrophy,  and  the  defor- 
mity characteristic  of  strumous  disease.  Yet  the  amount 
of  motion  and  the  exceptionally  clear  history  Dr.  Scott  gave 
me  rendered  the  diagnosis  comparatively  easy.  The  de- 
formity was  of  two  years'  standing,  and  there  was  phthisis 
in  both  father  and  mother.  This  strumous  diathesis,  I 
judge,  served  to  retard  recovery,  even  in  the  case  so  clearly 
rheumatic.  I  neglected  to  add  to  the  above  report  that  I 
found  joint  roughening  in  the  knee,  and  in  the  shoulder, 
the  elbow,  and  the  wrist.  A  year  later  the  right  hip  became 


8O  DISEASES  OF  THE  HIP. 

similarly  affected  but  a  rest  for  a  week  or  two  and  anti- 
rheumatic  remedies  served  to  avert  any  of  the  subsequent 
results  to  which  its  fellow  was  subjected. 

When  the  rheumatic  inflammation  is  limited  chiefly  to  the 
periosteal  tissues  in  close  proximity  to  the  capsular  liga- 
ment, signs  may  present  that  will  render  diagnosis  exceed- 
ingly difficult.  I  have  only  within  a  few  days  satisfactorily 
accounted  for  some  signs  that  I  found  in  the  fall  of  1880 
which  led  me  to  record  as  belonging  to  neuromimesis  and 
some  very  positive  signs  in  the  winter  of  the  same  year 
which  led  me  to  diagnosticate  a  chronic  articular  ostitis 
peripheral  and  periarticular  in  origin.  The  case  has  been 
very  puzzling  for  the  past  two  and  a  half  years  and  I  am 
just  now  firmly  convinced  that  I  have  unconsciously  had 
under  observation  all  the  while  a  very  interesting  form  of 
chronic  periarticular  rheumatism  of  the  hip.  The  case 
will  certainly  bear  a  detailed  history. 

A  boy  eight  years  of  age  was  transferred  from  the  Home 
for  the  Friendless  to  the  hospital  in  the  latter  part  of  Sep- 
tember, 1881,  without  a  reliable  history.  It  was  reported 
that  the  father  was  intemperate  and  worthless,  and  that 
the  mother  was  dead;  cause  not  known.  Six  or  seven 
weeks  prior  to  admission,  he  was  observed  to  walk  as  if 
something  ailed  his  ankles.  The  gait  was  unsteady,  he 
complained  at  the  beginning  of  pain  about  these  joints,  yet 
had  no  febrile  reaction,  did  not  take  his  bed,  and  in  fact 
was  not  regarded  as  a  sick  boy.  These  symptoms  were 
followed  within  two  or  three  weeks  by  pain  and  stiffness  at 
the  wrist  joints. 

On  examination  nothing  in  the  way  of  physical  signs 
could  be  discovered  save  some  rachitic  changes  the  sternum, 
in  the  sterno-clavicular  articulations  and  at  the  knees. 
While  the  gait  was  a  little  unsteady  there  was  no  lameness, 
and  no  spinal  tenderness  could  be  elicited.  There  was  no 
heart  murmur  that  I  could  discover.  When  asked  to  locate 
the  pain  he  pointed  to  the  knuckles  and  to  the  tibio-tarsal 
joints.  It  was  supposed  that  the  boy  was  anaemic,  and 
nothing  more. 

After  a  month's  observation  the  case  was  still  enveloped 
in  obscurity,  the  gait  was  evidently  that  of  an  ankle-limp, 
and  yet  I  could  not  detect  any  other  signs  of  articular  or, 
periarticular  disease.  The  whole  limb  was  hyperaethesic, 
the  dorsal  spine  was  quite  tender,  and  the  foot  had  been 
frequently  seen  hanging  in  equino-varus.  It  seemed  as  if 


RHEUMATISM   OF  THE  HIP.  8 1 

there  was  after  all  a  neurosis  of  spinal  origin — possibly  only 
a  neuromimesis.  Topical  treatment  was  directed  to  the 
spinal  area  of  tenderness,  and  there  was  a  decided  improve- 
ment noted  in  less  than  a  fortnight.  The  gait  did  not  be- 
come perfect,  however,  and  in  the  latter  part  of  December  I 
subjected  him  to  a  careful  examination  of  the  hip,  especially 
as  I  fancied  he  was  slowly  acquiring  the  hip-limp.  I 
selected  a  hard  table,  removed  all  the  clothing  and  found 
the  following  signs:  Rotation  inward  with  the  leg  fully 
extended  could  not  be  made  to  the  same  extent  as  could 
the  fellow  limb  under  the  same  circumstances,  the  limita- 
tion of  motion  was  very  marked;  the  thigh  could  be  flexed 
and  extended  and  abducted  over  as  complete  arcs  as  could 
corresponding  movements  be  made  in  the  other  limb. 
Negatively,  there  was  no  atrophy,  no  infiltration,  no  signs 
in  ilio-costal  space  or  iliac-fossa.  The  diagnosis  on  the 
strength  of  the  persistent  lameness  (so  light  that  it  could 
with  difficulty  at  times  be  recognized)  and  this  resistance 
to  perfect  rotation  was  recorded  as  chronic  ostitis,  prob- 
ably central,  in  the  neighborhood  of  the  hip-joint.  By  the 
middle  of  July,  1881,  the  lameness  was  more  marked  and 
was  regarded  as  characteristic,  yet  the  signs  at  the  hip  had 
not  increased.  After  an  intermittent  form  of  dysentery  in 
in  the  autumn  his  lameness  became  still  more  marked, 
and  in  December  he  complained  of  pain,  referring  it  to  a 
small  area  just  below  the  trochanter  major.  In  the  spring 
it  became  less  marked,  and  the  signs  seemed  so  insignifi- 
cant, that  in  July  even  expectant  treatment  was  suspended. 
He  enjoyed  perfect  (?)  immunity  from  symptoms  and  signs 
until  the  following  September  when  the  lameness  returned. 
He  complained  much  of  pain  in  the  hip,  and  there  was 
found  marked  joint  tenderness.  A  fly-blister  was  ordered, 
the  symptoms  subsided  soon  afterward,  and  in  November, 
another  was  applied.  He  was  worse  the  last  week  of 
December.  Without  any  special  treatment  he  recovered 
from  this  exacerbation,  and  has  continued  well  to  date.  Still, 
holding  on  to  the  diagnosis  of  bone  disease.  I  wondered 
why  the  evolution  was  so  slow,  and  on  the  last  day  of  July 
I  submitted  him  to  a  final  examination,  finding  no  lame- 
ness, no  deformity,  no  shortening,  no  resistance  to  rotation 
or  any  of  the  joint  movements.  In  fact,  all  that  I  did  find 
was  a  little  muscular  atrophy  back  of  the  trochanter  and  a 
half  inch  atrophy  of  the  thigh  in  its  upper  portion.  While 
as  above  noted  there  is  no  lameness  there  is  a  certain 


82  DISEASES   OF  THE   HIP. 

peculiarity  in  his  gait  difficult  to  describe.  He  has  now  a 
well-marked  mitral  regurgitant  murmur. 

At  all  events,  my  final  diagnosis,  of  his  case  is  this:  A 
chronic  rheumatic  arthritis  at  first  poly-articular,  finally 
monarticular,  the  lesions  in  the  last  joint  being  periarticu- 
lar  with  exacerbations,  the  joint  becoming  involved  by  con- 
tiguity at  these  times,  giving  rise  to  temporary  synovitis. 

Now  I  am  prepared  to  state  that  the  diagnosis  of  a  lesion 
like  the  one  in  the  case  I  have  just  reported  ought  to  be 
easy.,  i.e.,  with  a  knowledge  of  all  the  facts  I  had  in  my 
possession.  The  muscular  element  was  not  a  part  of  this 
case,  except  in  so  far  as  the  nerves  affected  the  muscles. 
The  same  law  holds  good  in  chronic  rheumatism,  that 
holds  good  in  other  chronic  diseases,  viz.,  the  law  of  ex- 
acerbation, and  with  this  before  our  minds,  the  peculiar 
phenomena  of  this  case  are  readily  explained.  At  first 
we  had  the  ankles  affected,  then  the  wrists,  both  perhaps  in 
separate  exacerbations.  A  little  later  came  the  hip  symp- 
toms, and  these  continued  with  long  remission  for  two  and 
one  half  years.  The  spinal  tenderness  and  hypersesthesia 
may  have  been  due  to  a  hypersemia  of  the  meninges  and 
may  thus  have  affected  the  nerves.  With  his  heart  lesion 
now  fully  developed,  the  final  outcome  of  the  case  is  a  ques- 
tion of  much  interest. 

The  disposition  of  a  rheumatic  periarthritis  to  invade 
after  long  intervals  the  joint  is  well  known  in  the  history 
of  this  disease.  We  have  at  present  a  boy,  nine  years  of 
age,  in  the  hospital,  who  came  several  years  ago  under 
treatment  for  chronic  articular  ostitis  of  the  knee.  There 
were  all  the  signs,  including  the  deformity,  that  go  to  make 
up  the  features  of  such  a  case,  and  under  the  usual  treat- 
ment a  surprisingly  good  result  was  had  within  a  few 
months.  It  seemed  very  odd  that  this  boy,  in  the  same 
ward  with  other  boys  who  were  even  less  deformed  than 
he,  should  so  far  outstrip  them  in  the  race  for  health  and 
soundness  of  limb,  yet  such  was  the  fact,  and  I  was  com- 
pelled to  think  of  his  case  as  an  anomalous  one.  After  a 
year  or  two  he  was  readmitted  with  similar  symptoms, 
greater  deformity,  and  in  addition  a  marked  distension  of 
the  synovial  sac.  Merely  an  unusually  acute  exacerbation, 
thought  I,  and  sure  enough  it  subsided  promptly  under 
rest  and  extension  apparatus.  Up  to  this  time,  bear  in 
mind,  he  had  not  exhibited  any  signs  in  any  of  the  other 
joints — but  a  few  months  later  the  other  knee,  after  a  con- 


RHEUMATISM    OF   THE   HIP.  83 

tusion  of  the  shin,  took  on  inflammatory  action,  and  the 
synovial  sac  soon  filled.  A  double  ostitis  now,  it  seemed  to 
me,  only  in  this  instance  the  synovlal  membrane  became 
quite  early  involved.  The  prognosis  was  gloomy  and  the 
case  caused  me  considerable  anxiety.  However,  these  symp- 
toms subsided,  contrary  to  expectations,  and  the  deformity 
of  both  limbs  was  overcome.  Later  still,  he  began  to  com- 
plain of  pain  at  his  left  tibio-tarsal  joint,  and  in  a  few  days 
redness  and  swelling  followed.  Then  it  dawned  upon  me 
that  this  was  a  case  of  chronic  rheumatism,  beginning  as  a 
monarticular  variety,  and  subsequently  involving  other 
joints.  Occasionally  a  case  presents  with  an  unmistakable 
rheumatic  history,  joint  swellings,  etc.,  and  subsequently 
develops  true  bone  disease.  One  is  inclined  to  believe  that 
even  bone  signs  are  but  rheumatic  signs  until  an  abscess 
forms. 

I  well  remember  in  all  the  details,  a  case  that  came 
under  my  care  in  1881.  It.  was  in  a  stout,  robust-looking 
girl,  eleven  ^years  of  age,  who  came  into  the  hospital  on 
August  z6th,  and  a  history  was  given  which  ran  about  as 
follows:  In  October,  1880,  she  began  one  day,  without  pro- 
vocation, so  far  as  the  family  could  learn,  to  complain  of 
pain  in  the  right  groin,  and  was  feverish;  two  days  later 
her  ankles  swelled,  the  febrile  symptoms  continuing,  and 
among  these  symptoms  profuse  perspiration.  In  a  week 
the  wrists  were  puffy  and  painful.  This  attack  kept  her  in 
bed  for  three  months,  and  for  two  months  longer  she  was 
unable  to  walk.  Since  March,  however,  she  had  been  get- 
ting about,  after  a  fashion,  on  crutches. 

I  found  on  examination  that  she  stood  with  her  weight 
on  the  left  limb,  the  right  nearly  parallel  with  this,  but 
rotated  outward  over  a  small  arc.  She  was  not  able  to 
walk  without  crutches.  The  right  natis  was  very  broad 
and  quite  prominent,  the  crease  lowered.  This  fulness  at 
the  nates  extended  along  the  thigh  in  its  upper  third. 
Resistance  was  offered  to  extension  of  the  limb  beyond 
165°,  flexion  was  very  nearly  perfect;  on  rotation,  which 
was  limited  to  a  small  arc,  a  distinct  roughening  could  be 
felt  within  the  joint.  There  was  no  joint  tenderness 
elicited  b)r  examination.  I  could  get  no  articular  rough- 
ening at  the  knee,  but  at  the  ankle-joint  the  roughening  was 
present  and  the  movements  were  limited  to  very  small  arcs. 
The  left  ankle-joint  presented  limited  movements,  but  it 
was  not  so  with  the  knee  arid  the  hip  of  this  side.  Ther§ 


84  DISEASES  OF  THE  HIP. 

was  very  little  atrophy,  and  while  the  limb  was  really  an 
inch  shorter,  as  measured  from  the  anterior  superior  spinous 
process  the  pelvic  accommodation  was  such  that  there  was 
no  practical  shortening.  There  was  no  heart  murmur. 
After  two  and  a  half  months  an  abscess  developed  on  the 
outer  side  of  the  thigh  in  the  middle  third,  and  there  was 
extensive  infiltration  of  the  inguinal  glands.  A  month 
later  she  passed  from  under  my  observation.  I  found  be- 
fore she  left  that  the  thigh  could  not  be  flexed  beyond  90° 
or  extended  beyond  150°.  The  abscess  had  not  opened. 
Now,  one  would  naturally  expect  from  this  girl's  history 
and  from  the  signs  recognized  within  the  joint,  that  her  hip 
lesion  was  rheumatic,  and  yet  the  suppuration  coming  on 
later  would  dispel  this  opinion,  and  the  natural  inference 
would  be  that  the  bone  disease,  or,  suppurative  periarticular 
disease  was  coincidental.  The  roughening  within  the  joint 
was  exactly  like  that  found  in  the  ankle-joints.  It  is  not  so 
very  rare  to  find  periosteal  suppuration  about  other  joints 
that  are  rheumatic.  I  think,  though,  that  if  a  careful  ex- 
amination be  made,  with  the  proper  interpretation  of 
symptoms  and  signs,  it  will  not  be  impossible  to  separate 
the  one  from  the  other. 

Now,  a  case  like  that  of  a  boy  whom  I  saw  in  the  spring 
of  1881  is  not  so  misleading.  He  came  under  treatment  for 
chorea  minor  of  seven  weeks'  standing.  On  the  subsid- 
ence of  this  disease  he  developed  a  subacute  polyarticular 
rheumatism.  This  was  two  months  after  he  had  come 
under  treatment,  and  among  the  first  symptoms  were  pains 
in  the  knee  and  thigh  of  the  right  side.  About  the  same 
time  he  walked  lame,  favoring  this  side.  It  was  not  a 
characteristic  hip-limp,  yet  my  suspicions  were  aroused  and 
I  gave  him  a  pretty  thorough  examination,  getting  nega- 
tive results,  with  this  exception;  I  could  not  make  normal, 
abduction.  Under  salicylate  of  soda  he. walked  perfectly 
well  in  less  than  a  week.  But  during  this  week  the  other 
hip  presented  the  same  sign.  I  saw  him  a  month  after- 
ward and  he  had  no  relapse.  Of  course,  with  the  absence 
of  deformity  at  the  hip  and  the  puffiness  at  the  ankle,  one 
could  not  well  arrive  at  any  other  diagnosis  than  that  of 
subacute  rheumatism. 

Having  illustrated  the  different  phases  of  rheumatism  as 
it  affects  the  hip,  both  as  an  extra-articular  and  an  intra- 
articular  lesion,  I  feel  that  one  who  understands  the  symp- 
tomatology of  rheumatism  in  its  different  forms,  and 


aiw; 

Xatte 
f       in  £ 


RHEUMATISM   OF  THE   HIP.  85 

examines  the  case  with  the  fulness  of  detail  that  an  obscure 
case  should  always  demand — I  feel,  I  say,  quite  sure  that 
no  flagrant  error  will  be  committed  in  diagnosis.  The 
prognosis  is  nearly  always  good,  both  as  to  life  and  as  to 
perfect  restoration  of  function.  If  death  ever  does  occur, 
it  occurs  from  the  heart  complication.  If  deformity  per- 
sists it  grows  less  marked  in  time,  and  the  ultimate  result 
may  be  complete  cure.  The  myalgic  affections  are  very 
favorable  as  to  prognosis.  Even  if  recurrence  of  symp- 
toms come  on  the  tendency  is  not,  like  bone-disease,  to  im- 
pair the  tissues  more  and  more  after  successive  exacerba- 
tion, but  to  gradually  wear  itself  out.  The  tendency  is 
always  toward  recovery. 

HE  TREATMENT  of  rheumatism  need  not  occupy  our 
attention  long,  for  this  is  well  considered  in  all  text-books 
in  general  medicine.  Of  course,  if  one  makes  the  diagnosis 
of  muscular  rheumatism  in  a  child  there  is  no  special  treat- 
ment indicated.  The  treatment  on  general  principles  will 
yield  good  results.  It  is  the  deformity  we  are  called  upon 
to  treat,  and  this  sometimes  becomes  very  difficult.  The 
majority  of  cases  of  stiff,  or  partially  stiff,  rheumatic  joints 
require  passive  motion  under  an  anaesthetic.  This  treat- 
ment is  the  orthodox  treatment,  but  many  find  that  poul- 
ticing the  parts  for  several  weeks  and  then  employing 
passive  motion  is  very  effective.  This  is  the  plan  essentially 
of  the  "  bone-setters,"  and  the  success  with  which  they 
meet  should  induce  us  to  make  more  frequent  use  of  it. 
Passive  motion  without  an  anaesthetic  only  induces  muscur 
lar  resistance,  and  on  each  attempt  the  resistance  is  the 
greater.  I  am  not  speaking  now  of  the  plan  wherein  prer 
vious  poulticing  forms  an  essential  part  of  the  treatment. 
In  studying  cases  of  anchylosis  of  the  hip,  in  which  bone- 
setters  have  achieved  success,  I  find  that  their  most  brilliant 
results  have  been  in  rheumatic  cases. 

An  important  question  in  therapeutics  is  this  :  should 
the  parts  be  put  at  rest  for  a  week  or  two  after  a  brisement 
force  under  an  anaesthetic,  or  should  passive  motion  be  con- 
tinued daily  without  the  anaesthetic?  In  other  words,  how 
long  should  one  wait  to  begin  such  daily  motion.  There 
*is  testimony  on  both  sides,  but  I  am  very  sure  that  I  have 
seen  the  best  results  in  cases  where  at  least  a  week's  rest,, 
followed  the  operation. 

I  saw  a  case  about  a  year  and  a  half  ago,  in  a  young  girl 
eighteen  years  of  age.     {Both  hips  had  become  horribly 


86  DISEASES  OF  THE  HIP. 

deformed  after  an  acute  attack  of  rheumatism.  She  was 
entirely  helpless,  and  the  ankylosis  seemed  almost  com- 
plete. For  months  she  had  not  been  out  of  an  invalid 
chair.  The  patient  came,  on  my  recommendation,  under 
the  care  of  Dr.  Jno.  H.  Ripley,  in  St.  Francis  Hospital. 
He  employed  great  force  under  an  anaesthetic  in  freeing 
the  right  hip  of  its  adhesions,  and  placed  it,  after  a  few 
movements  in  flexion  and  extension,  at  an  angle  of  about 
150°  and  put  the  parts  at  rest.  He  did  not  repeat  the  ope- 
ration for  several  weeks,  and  then  the  force  was  very  slight. 
Two  operations  on  this  limb  served  to  bring  it  not  only  in 
good  position,  but  to  bring  about  a  good  arc  of  motion. 
Later  he  moved  the  left  hip,  and  found  the  adhesions  here 
much  greater  than  those  of  the  right  side.  The  final  out- 
come was  a  pair  of  limbs  with  which  she  could  go  about 
with  comparative  ease. 

Mr.  Brodhurst  very  properly  insists  on  complete  flexion 
in  these  attempts.  Extreme  extension  should  be  avoided 
for  fear  of  surgical  fracture. 

II. 

CHRONIC    RHEUMATIC    ARTHRITIS   (MALUM   COXJE-SENILE). 

We  find  a  disease  of  the  hip  appearing  in  the  latter  part 
of  adult  life,  described  by  authors  as  malum  coxae  senile, 
and  while  there  are  many  cases  in  which  no  rheumatic  his- 
tory can  be  found,  the  impression  prevails,  nevertheless,  that 
there  is  a  rheumatic  diathesis  present,  called  into  action 
by  traumatic  .influence.  I  have  met  with  a  large  number 
of  cases,  and  I  must  confess  that  I  fail  to  find  in  the  ma- 
jority any  characteristic  rheumatic  element  present.  The 
inception  is  not  marked  by  notable  symptoms.  Frequently 
it  is  not  unlike  that  of  a  chronic  articular  ostitis.  Bone 
changes  do  occur,  yet  they  occur  as  a  result  of  osteo- 
plastic  inflammation,  and  then  we  have  more  properly  an 
arthritis  deformans. 

The  pathological  changes  are  not  constant  enough  to 
assign  to  the  clinical  features  of  the  disease  a  name 
based  on  morbid  anatomy.  In  some  cases  the  structures 
within  and  without  the  joint  are  implicated  to  a  large  ex- 
tent, and  resolution  occurs  to  such  a  degree  that  one  ap- 
preciates on  late  examination  nothing  more  than  the  char- 
acteristic intra-articular  grating  of  chronic  rheumatism. 
In  some  cases,  again,  the  tissues  immediately  involving  the 
joint,  such  as  the  ligaments  and  periosteum,  seem  to  be  the 


CHRONIC  RHEUMATIC  ARTHRITIS.  87 

only  structures  involved,  and  the  resistance  to  movement 
in  the  convalescent  period  depends  on  periarticular  adhe- 
sions. While  in  another  and  a  more  formidable  class, 
bony  changes  take  the  form  of  osteophites,  or  stalactites, 
locking  in  a  measure  the  articulation.  If  one  looks  over 
the  pathological  specimens  in  the  different  museums  a  feel- 
ing of  therapeutical  despair  comes  over  him  as  he  examines 
the  old  rheumatoid  hips.  The  head  of  the  bone  has  assumed 
all  manner  of  shapes;  osteophites  and  stalactites  encircle 
the  rim  in  irregular  arrangement,  the  cartilage  has  disap- 
peared, and  one  really  wonders  how  any  measures  looking 
toward  the  restoration  of  the  joint  functions  could  have 
ever  been  sucsessful. 

It  is  a  clinical  fact,  notwithstanding  these  cabinet  curios- 
ities, that  much  in  the  way  of  relief,  either  through  time 
or  therapeutics,  is  accomplished.  It  is  also  a  clinical  fact 
that  the  ankylosis  is  in  many  cases  far  from  complete,  and 
that  a  patient  with  a  limited  amount  of  motion,  and  with 
the  limb  not  deformed  to  any  exaggerated  degree,  gets 
about  quite  comfortably. 

Before  proceeding  to  the  clinical  history  of  these  chronic 
forms  of  rheumatism  occurring  in  persons  beyond  the  age  of 
forty  or  fifty,  I  shall  refer,  at  least,  by  way  of  illustration, 
to  certain  forms  that  begin  as  acute,  or  subacute  inflamma- 
tions, and  are  found  in  adult  life  prior  to  the  age  of  forty. 

A  very  good  case  for  study  came  under  my  observation 
in  1879,  in  the  person  of  a  vigorous  looking  man  twenty- 
five  years  of  age.  His  vocation  for  several  years  had  ex- 
posed him  much  to  cold  and  wet  weather,  and  in  the  win- 
ter of  1876-77  he  had  an  attack  of  what  was  called  lumbago, 
from  which,  however,  he  recovered  in  two  or  three  months. 
In  the  spring  of  1877  he  was  thrown  violently  from  a  sleigh, 
striking  upon  the  left  hip,  but  was  not  bruised  in  the  exter- 
nal parts  so  far  as  he  could  determine.  Yet  he  was  stiff 
and  lame  for  a  week  or  two  thereafter  and  suffered  a  mod- 
erate amount  of  pain  at  the  hip.  Within  two  weeks  the 
symptoms  subsided  and  he  was  quite  well  again. 

A  week  later,  after  unusual  exposure  to  wet  weather,  he 
"  took  cold,"  and  this  "  seemed  to  settle  in  his  joints."  The 
hip,  knee  and  ankle-joints  were  affected.  The  two  last 
named  were  much  swelled,  very  painful,  and  very  tender. 
He  suffered  also  from  shooting  pains  in  the  thigh  and  groin, 
yet  he  did  not  give  up  work  for  a  month.  The  symptoms 
and  the  signs  became  so  severe  that  he  finally  had  to  de- 


88  DISEASES  OF  THE  HIP. 

sist,  and  for  a  couple  of  months  he  was  barely  able  to 
hobble  about  on  crutches.  Then  the  knee  and  the  ankle 
symptoms  subsided,  while  the  hip  was  subjected  to  treat- 
ment by  weight  and  pulley  and  a  hip-splint  for  a  year.  At 
one  time  in  the  early  part  of  the  extension  treatment  there 
was  very  annoying  reflex  muscular  spasm  about  this  joint. 
On  examination  I  find  four  inches  atrophy  of  the  thigh; 
resistance  to  flexion  beyond  an  angle  of  135°,  to  extension 
beyond  165°,  to  complete  abduction,  and  to  both  adduction 
and  rotation  even  to  a  limited  degree.  Pain  is  feit  in 
the  joint  and  in  the  distribution  of  the  sciatic  nerve  on 
concussion  and  on  pressure  over  the  trochanter.  The  in» 
guinal  glands  are  large,  and  the  natis  is  flattened.  There  is 
moderate  lordosis.  Under  ether  the  thigh  was  moved  over 
a  large  arc,  and  adhesions  apparently  within  the  joint  were 
pretty  thoroughly  broken  up,  but  no  bony  grating  could  be 
recognized.  The  muscular  resistance  which  before  was  so 
marked  had  now  disappeared.  There  was  some  muscular 
resistance,  however,  to  complete  extension.  I  could  not  de- 
tect any  real  shortening  of  the  limb,  but  there  was  an  ap- 
parent shortening  of  a  half  inch.  The  circumference  of 
the  thigh  measured  four  inches  less  than  that  of  the  right, 
and  the  calf  measured  one  inch  less.  No  rheumatic  signs 
could  be  discovered  at  the  knee  or  at  the  ankle.  On  com- 
ing out  from  the  anaesthetic  the  movements  could  be  made 
quite  as  easily,  though  the  muscles  were  so  deficient  in  tone 
that  he  could  not  voluntarily  flex  and  extend.  In  other 
words,  there  was  found  the  remains  of  an  arthritis  and  a 
marked  loss  of  power  in  the  periarticular  muscles.  The 
faradic  reactions  were  good,  thus  eliminating  a  true  paral- 
ysis. 

Now,  while  the  man  presented  a  case  of  true  joint-disease, 
with  the  characteristic  muscular  atrophy,  the  process  had 
been  unusually  acute,  and  yet  I  can  not  help  believing  that 
the  same  tissues  were  involved  as  are  involved  in  older  per- 
sons. Senile  changes  in  tissues  we  know  proportionately 
modify  the  inflammation.  That  this  was  a  case  of  monar- 
ticular  rheumatism,  although  apparently  excited  by  trauma, 
I  think  there  is  abundant  evidence. 

I  had  an  opportunity  of  seeing  a  case  in  the  active  stage. 
The  patient  was  a  commercial  traveler,  and  he  was  thirty- 
nine  years  of  age.  He  was  very  helpless,  and  any  attempt 
at  passive  movement  of  the  right  hip  caused  great  pain. 
The  whole  groin  and  gluteal  region  were  infiltrated  to  a 


CHRONIC  RHEUMATIC  ARTHRITIS.  89 

marked  degree;  the  limb  was  lying  nearly  parallel  with  its 
fellow,  but  was  in  outward  rotation.  There  was  no  real 
shortening,  the  position  of  the  pelvis  giving  a  shortened  ap- 
pearance to  the  limb. 

The  parts  about  the  knee  were  the  seat  of  pain  and  swel-1 
ling.  He  had  been  suffering  very  acutely  for  two  weeks  or 
more  and  was  much  exhausted.  Hence  my  examination 
was  not  very  satisfactory. 

The  first  symptoms  were  a  heavy  dragging  feeling  and 
pain  in  the  right  thigh,  three  months  before.  He  had  been 
much  exposed  to  damp  weather  while  travelling  in  the 
West.  The  symptoms  were  aggravated  by  walking;  in  fact, 
it  was  not  more  than  a  week  before  he  was  confined  to  bed 
with  the  usual  constitutional  disturbance  of  an  inflam- 
matory disease.  The  inguinal  glands  soon  became  infil- 
trated, and  the  physician  in  attendance  found  suppuration. 
After  a  six  days'  exacerbation,  he  had  a  remission  lasting 
two  or  three  weeks.  The  symptoms  subsided,  but  the 
lameness  and  stiffness  of  the  hip  continued  without  abate- 
ment. A  relapse  followed. 

I  saw  him  January  23d,  and  employed  hot  fomentations. 
He  was  able  to  get  about,  on  crutches  by  the  first  of  Febru- 
ary. Anti-rheumatics  were  administered,  massage  em- 
ployed and  later  the  faradic  current  was  used  daily  for  a 
couple  of  weeks.  By  April  ist  he  was  walking  without 
any  assistance,  the  limb  presented  very  little  deformity,  and 
he  went  "  on  the  road  "  again,  pursuing  his  vocation.  He 
made  a  very  fair  recovery. 

The  case  illustrates  a  clinical  fact  recognized  throughout 
the  whole  range  of  medicine,  viz.,  that  acute  diseases  resolve 
with  infinitely  less  impairment  of  function  than  those  that 
are  essentially  chronic  in  nature.  My  prognosis  in  this  in- 
stance had  been  gloomy  enough. 

In  the  early  part  of  the  present  year,  a  man  fifty  years  of 
age,  came  under  my  care  for  a  peripheral  paralysis,  and  I 
saw  in  him  a  peculiar  limp  that  led  me  to  examine  the  hip, 
which' was  found  ankylosed  in  the  straight  position.  He 
claimed  to  have  been  perfectly  well  two  years  ago,  and  to 
have  come  of  a  family  free  from  any  rheumatic  disease. 
-'Never  in  all  his  life  had  any  other  joints  been  affected.  In 
1869,  a  man  gave  him  a  kick  in  the  groin,  and  the  superficial 
parts  suffered  contusion,  which  was  followed  by  pain 
and  lameness  for  six  months.  He  did  not  give  up  work  and 
had  no  special  line  of  treatment,  but  gradually  got  better, 


QO  DISEASES  OF  THE  HIP. 

and  within  less  than  a  year  the  functions  of  joint  were  re- 
garded as  normal. 

There  was  no  return  of  symptoms  or  signs  until  the  be- 
ginning of  1881,  when  his  attention  was  drawn  to  the  limb 
again  by  a  peculiar  cramp-like  feeling  in  the  groin  immedi- 
ately before  or  after  a  storm.  He  found,  too,  that  the  joint 
this  year  was  not  so  useful.  He  favored  it  at  first  and 
finally  a  well-marked  limp  was  manifest.  At  no  time  has 
he  been  compelled  to  give  up  work,  and  at  no  time  has  he 
had  any  very  acute  exacerbation.  The  case,  it  would  seem 
from  the  history,  had  progressed  slowly  and  almost  without 
an  incident.  What  connection  the  lesion  fourteen  years  ago 
has  with  present  one  it  is  hard  to  determine.  That  the  case 
at  present  is  one  of  senile  joint-disease  I  am  well  sat-isfied. 

I  knew  a  man  fifty  eight  years  of  age  who  attributed  a 
similar  condition  of  the  hip  to  the  wearing  of  a  truss,  and  a 
surgeon  of  world-wide  reputation,  after  examining  him  on 
two  different  occasions,  wrote  me  that  he  looked  upon  the 
truss  as  the  cause  of  the  chronic  rheumatic  arthritis  !  The 
hernia  first  appeared  at  the  age  of  fifty-five.  A  year  later, 
he  began  to  walk  lame,  and  during  the  next  twelve  months 
the  following  signs  slowly  developed:  limitation  in  the  arc 
of  motion,  morning  stifness,  pain  in  hip  after  a  storm,  rota- 
tion outward,  and  apparent  shortening.  I  could  not  elicit 
any  facts  pointing  to  a  rheumatic  element  either  in  himself 
or  in  any  member  of  the  family.  He  walked  when  I  first 
saw  him  (which  was  two  years  after  the  first  symptom)  with 
a  very  marked  limp  and  was  compelled  to  use  a  cane. 
From  both  the  umbilicus  and  the  anterior  superior  spine 
I  made  out  an  inch  and  a  half  shortening  of  the  limb.  The 
natis  was  very  broad  and  while  the  trochanter  stood  out 
very  conspicuously  from  the  pelvis,  it  did  not  appear  above 
Nelaton's  line.  The  position  was  slight  flexion,  and  abduc- 
tion. The  limit  to  extension  was  160°,  to  flexion  135°,  and; 
the  arc  of  rotation  was  very  small.  Abduction  was  resisted 
the  moment  the  act  was  attempted.  I  could  not  recognize 
any  joint  grating,  but  there  was  a  peculiar  crackling  sensa- 
tion imparted  to  my  hand  as  I  moved  the  hip.  This  I  found 
was  in  the  periarticular  tissue.  The  thigh  was  three  inches 
smaller  than  its  fellow,  and  the  knee  and  the  calf  one  inch 
respectively. 

Now  the  two  cases  I  have  just  narrated  show  quite  clearly 
the  clinical  history,  and  from  these  and  others  we  can  learn- 
that: 


CHRONIC   RHEUMATIC  ARTHRITIS.  9! 

1.  The  invasion  is  not  marked  by  any  distinct  train  of 
symptoms. 

2.  The  progress  is  exceedingly  slow,  and  marked  by  long 
remissions  and  short  exacerbations. 

3.  The  signs  are,  first,  stifness;  second,  change  in  position 
of  limb;  third,  shortening. 

4.  That  a  clear  rheumatic  history  is  absent  in  the  major* 
ity  of  cases. 

Exceptionally,  however,  we  do  get  a  well-marked  rheu- 
matic history.  My  attention  was  called  to  a  case  while 
writing  this  chapter  in  which  a  chronic  polyarticular  rheu* 
matism  began  first  in  the  right  hip,  slowly  invading  the 
right  knee,  then  the  left  hip  and  the  left  knee.  On  examin- 
ation I  find  the  left  hip  strongly  adducted  and  the  foot 
everted,  while  the  other  signs  are  further  characteristic  of 
joint-disease.  The  right  is  limited  as  to  movement,  and 
the  knees  on  movement  impart  to  one's  hand  the  distinct 
rice-body  sensation. 

The  diagnosis  is  not  always  unattended  with  difficulty. 
I  have  seen  cases  of  sciatica  with  the  peculiar  deformity, 
pain  on  movement,  and  periarticular  infiltration  that  belong 
to  rheumatic  hips. 

As  a  rule,  the  neural  symptoms  are  sufficiently  well  marked 
to  enable  one  to  decide  the  question  in  a  differential  diag- 
nosis. Anterior  crural  neuralgia  gives  more  of  the  neural 
signs  that  belong  to  rheumatic  arthritis  of  the  hip  than  does 
sciatica. 

A  good  point  in  differential  diagnosis  between  sciatica 
and  joint-disease  is  this:  place  the  thumb  of  your  hand  cor- 
responding to  the  hip  involved  over  the  tuber  ischii,  the 
middle  finger  over  the  trochanter,  and  the  tip  of  the  index 
finger  fully  extended,  will  fall  over  that  part  of  the  gluteal 
region  along  which  the  great  sciatic  passes. 

Pressure  now  with  the  index-finger  will  elicit  pain  in  the 
terminal  branches  of  the  nerve.  If  painful  sensations  do 
not  follow  this  procedure,  take  the  other  hand  and  place 
thumb  and  tip  of  middle  finger  over  trochanter  and  tuber 
ischii  as  above.  The  tip  of  the  index-finger  will  fall  over 
the  capsular  ligament,  and  deep  pressure  here  will  produce 
pain  in  the  joint.  This  simple  test  I  have  found  very  ser- 
viceable in  practice. 

Fracture  of  the  neck  of  the  femur  presents  many  signs 
in  common  with  senile  arthritis,  and  the  differential  diag- 
nosis becomes  very  awkward  if  the  fractures  have  been  im* 


02  DISEASES  OF  "THE  HIP. 

pacted.  The  solution  of  the  question  will  rest  largely  ofl 
the  history  of  the  invasion.  If  one  learns  that  the  patient 
within  the  first  week  following  the  injury  was  confined  to 
bed,  or  was  unable  to  walk,  and  that  several  weeks  elapsed 
before  the  ability  to  walk  was  regained,  presumptive  evi- 
dence is  furnished  in  favor  of  a  fracture.  And  a  fair  amount 
of  cross-examination  in  a  patient,  however  stupid  he  may 
be,  will  enable  one  to  judge  whether  the  disease  began  in- 
sidiously or  not.  The  greatest  obstacle  in  the  way  of  mak- 
ing a  diagnosis  is  incomplete  examination.  The  ease  with 
which  one  can  glance  at  a  hip,  estimate  measurements  by 
the  eye,  and  take  for  granted  certain  probabilities  as  facts, 
will  always  be  a  stumbling  block  in  the  way  of  correct 
diagnosis. 

THE  TREATMENT  of  chronic  rheumatic  arthritis  of  the 
hip  is  not  so  simple  as  one  would  imagine.  It  is  not  as  easy 
to  secure  rest  in  the  adult  as  it  is  in  the  child.  Time  is  of 
more  value  to  one  than  it  is  to  the  other.  Naturally  it 
would  seem  that  counter-irritation  in  a  disease  so  sluggish 
is  a  very  important  factor  in  therapeutics.  It  is  exceedingly 
hard,  though,  to  carry  out  a  thorough  course  of  counter- 
irritation  outside  the  wards  of  a  hospital.  The  disease,  too, 
will  have  made  considerable  progress  before  medical  or 
surgical  advice  is  sought.  The  family  physician,  it  may  be, 
is  asked  in  a  casual  way  about  this  peculiar  stifness,  or  this 
pain  after  exercise.  A  liniment  may  be  ordered  and  direc- 
tions given  the  patient  to  "  call  in  some  time'  soon "  and 
submit  to  a  thorough  examination.  Temporary  relief  may 
follow  the  application  of  the  liniment;  the  case  goes  into  a 
remission,  and  the  thorough  examination  is  not  made.  It 
is  so  easy,  too,  to  tell  the  patient  that  this  is  simply  a  neu- 
ralgia, or  a  cold,  or  a  strain,  or  an  infirmity  of  age.  Finally 
when  the  stage  of  shortening  and  deformity  appears,  the 
examination  is  made  for  the  first  time.  So  that  treatment 
rarely  begins  until  this  period  is  reached.  My  own  experi- 
ence in  the  use  of  the  iodides  and  of  the  salicylates  does  not 
enable  me  to  speak  with  any  confidence  as  to  the  value  of 
these  remedies.  If  fibrous  ankylosis  exists,  I  favor  break- 
ing up  the  adhesions  under  an  anaesthetic  and  the  subse- 
quent employment  of  faradism  and  massage  to  the  muscles 
that  have  been  so  long  in  disuse.  I  have  seen  some  deci- 
dedly good  results  follow  this  plan  of  treatment.  I  have 
already  reported  a  case  on  page  87,  in  which  the  result 
was  very  gratifying. 


CHRONIC  RHEUMATIC  ARTHRITIS.  93 

Dr.  H.  P.  Geib,  of  Stamford,  asked  me  to  see  a  case  with 
him  last  spring,  and  as  the  clinical  history  is  not  only  well 
illustrated,  but  also  the  value  of  the  treatment  I  have  just 
advised,  I  propose  giving  some  of  the  more  important  de- 
tails. The  patient  was  a  gardener  of  robust  frame,  forty- 
seven  years  of  age,  and  had  always  been  in  good  health 
prior  to  the  beginning  of  his  present  infirmity.  About  a 
year  ago,  while  much  .exposed  to  wet  weather,  he  first  ex- 
perienced a  dull  pain  in  the  vicinity  of  the  hip  and  at  the 
knee.  It  did  not  cause  him  much  annoyance  until  lameness 
came  on  a  few  weeks  afterward.  No  interest  was  aroused 
in  his  case  because  he  rarely  made  any  complaint.  Exacer- 
bations of  pain  and  stifness  were  induced,  he  thought,  by 
weather  changes.  Still  he  became  more  lame,  the  lameness 
increasing  very  slowly,  yet  even  this  did  not  occasion  any 
alarm.  I  found  him  standing  with  the  right  limb  ad- 
vanced, in  slight  flexion  and  outward  rotation.  He  walked 
exactly  like  one  who  had  made  an  unsatisfactory  recovery 
from  a  fracture  of  the  neck  of  the  femur.  There  was  a 
half-inch  real,  and  an  inch  and  a  half  practical,  shortening 
of  the  limb,  one  inch  atrophy  of  the  thigh  and  no  atrophy 
of  the  calf.  The  thigh  was  fixed  on  the  pelvis  at  an  angle 
of  165°;  though  if  a  little  force  were  employed  a  small  arc 
of  motion  was  secured,  and  at  the  same  time  a  crackling 
sensation  was  felt,  as  if  adhesions  in  the  joint  were  giving 
way.  The  changes  in  the  appearance  of  nates  were  very 
marked  and  very  characteristic. 

What  pain  he  had  was  referred  to  the  trochanter  and  in 
the  course  of  the  anterior  crural.  I  could  not  get  any  evi- 
dences of  rheumatism  in  the  history,  or  any  account  of  a  fall 
or  injury  as  exciting  cause.  Blisters  and  anti-rheumatics  did 
not  effect  any  good,  and  two  months  afterward,  assisted  by 
Drs.  Geib  and  Hungerford,  I  broke  up  the  adhesions  very 
easily  under  ether.  He  was  kept  at  rest  in  bed  two  weeks 
and  the  operation  was  repeated.  Finally  it  could  be  done 
without  an  anaesthetic;  the  parts  were  soon  quite  free  of  any 
resisting  bands  and  under  friction  and  rubbing  the  recovery 
was  nearly  complete  when  I  last  heard  from  the  patient. 

When  the  exacerbations  are  present  symptoms  are  to  be 
treated,  and  for  the  pain  hot  fomentations  yield  the  best 
results.  Stimulating  liniments  naturally  suggest  them- 
selves, and  pain  disappears  after  a  few  applications.  Anti- 
rheumatics  internally  certainly  modify  the  duration,  and 
whichever  drug  the  practitioner  is  best  pleased  with  is 
the  drug  to  employ. 


CHAPTER  VI. 

Coxo- FEMORAL  PERI  ARTHRITIS. 

The  abundance  of  cellular  tissue  about  the  hip,  the  ex- 
tent of  the  fascia  superficial  and  deep,  and  the  exposure  of 
the  parts  to  traumatism,  render  this  region  peculiarly 
liable  to  inflammatory  conditions,  usually  acute  in  char- 
acter. 

The  lesion,  as  a  rule,  is  confined  to  the  soft  parts,  and  the 
inflammatory  products  are  bound  down  by  the  dense  fas- 
cia and  the  muscles  thus  restricting  the  joint  movements  to 
small  arcs.  In  rheumatism  the  seat  of  the  disease  is  in  the 
fibrous  tissues,  the  joint,  the  aponeurses,  the  sheaths  of  the 
tendons,  the  neurilemma,  the  periosteum  or  the  muscles 
and  tendons.  Hence,  with  so  many  tissues  involved  we  can 
not  with  propriety  speak  of  rheumatism  as  a  periarthritis. 
The  term  is  preferable,  I  think,  to  extra-capsular  abscess 
because  it  does  not  commit  us  to  a  suppurative  form  of  in- 
flammation. 

It  is  often  phlegmonous;  and  when  it  involves  the  gluteal 
region  we  speak  of  it  simply  as  a  phlegmon. 

The  exciting  causes  are  varied,  contusion  and  sprain  be- 
ing the  most  frequent.  Some  cases  follow  in  the  wake  of 
an  exanthem.  A  few  are  glandular  and  are  decidedly 
scrofulous. 

The  pathology  of  periarthritis  in  adults  differs  from  that 
in  children.  The  term  was  first  employed  by  M.  Duplay 
to  represent  a  condition  about  the  scapulo-humeral  ar- 
ticulation that  had  been  long  recognized,  viz.,  a  chronic  or 
subacute  inflammation  of  the  fibrous  structure  immediately 
surrounding  the  joint,  and  dependent  on  trauma.  M.  Gos- 
selin  described  cases  in  which  the  tibio-femoral  articula- 
tion was  involved.  The  reason  these  authors  gave  for  ex- 
cluding rheumatism  was  that  the  lesions  were  monarticular 
and  were  free  from  rheumatic  history.  The  behavior  is 
practically  the  same.  Exacerbations  are  followed  by  ad- 
hesions limiting  the  joint  functions  and  inducing  recurring 
attacks  of  an  arthritis  by  contiguity.  I  do  not  know  of 


COXOFEMORAL  PERIARTHRITIS.  95 

any  post-mortem  observation  demonstrating  a  similar  lesion 
at  the  hip.  I  have  not  had  an  opportunity  of  verifying  my 
own  diagnosis  in  such  cases.  In  a  few  I  have  reached  the 
diagnosis  by  exclusion,  and  I  should  like  to  place  them  on 
record,  but,  then,  on  reflection  I  do  not  see  what  service  they 
can  render  to  pathology.  I  have  had  under  observation 
for  seven  or  eight  years,  a  girl  now  aged  fifteen,  and  I  am 
unable  to  decide  upon  anything  further  than  a  chronic 
fibrous  periarthritis.  I  think  a  strong  case  could  be  made 
out  but  I  shall  await  further  developments. 

When  one  remembers  how  well  protected  the  hip-joint 
is  against  injuries  of  the  fibrous  tissues,  the  infrequency  of 
such  lesion  is  readily  explained. 

As  I  have  nothing  clinical  to  offer  bearing  upon  these 
chronic  ligamentous  forms  of  inflammation,  I  have  limited 
myself  to  the  acute  and  chronic  cellular  periarthritis. 

The  youngest  patient  I  have  had  was  a  female  aged  five 
weeks,  the  cellulitis  beginning  when  three  weeks  of  age  and 
terminating  in  resolution  at  the  end  of  three  weeks.  In  an 
analysis  of  forty-seven  cases  of  periarthritis  of  the  different 
joints  made  a  few  years  ago,  I  found  twenty  for  the  hip, 
sixteen  for  the  knee,  six  for  the  ankle,  three  for  the  sacro- 
iliac  junction,  and  two  for  the  spine. 

The  symptoms  vary  according  to  the  regions  implicated. 
The  invasion  is  nearly  always  acute,  the  patient  experiences 
sharp  pain,  increased  heat  of  the  skin  and  induration  with 
fluctuation  if  suppuration  follows.  As  a  rule,  this  is  an  acute 
disease  and  exceptions  are  rare.  A  case  I  have  already 
placed  on  record  in  the  American  Journal  of  the  Medical 
Sciences  forms  a  notable  exception  and  is  as  follows: 

A  female,  aged  three  years,  to  all  appearances  well  nour- 
ished, was  admitted  to  the  hospital  the  middle  of  December, 
1875.  The  father  and  mother  had  good  family  histories, 
while  the  child  herself  was  reported  as  having  enjoyed 
peculiar  immunity  from  the  diseases  of  infancy.  Began  to 
walk  lame  one  year  prior  to  admission,  and  no  cause  could 
be  assigned.  This  was  the  only  sign  observed,  until  within 
the  last  few  weeks,  when  pain  was  complained  of  in  the 
back,  and  this  pain  was  increased  by  any  jar  or  turning. 
The  child  was  restless  and  wakeful  at  night.  About  one 
month  ago  a  plaster  of  Paris  jacket  was  applied  by  a  phy- 
sician for  suspected  spinal  disease.  This  proved  very  un- 
comfortable, and,  failing  to  give  support  to  which  the  child 
could  accustom  itself,  was  removed  by  the  mother,  without 


96  'DISEASES  OF  THE  HIP. 

consulting  the  physician,  at  the  end  of  two  weeks,  when  a 
swelling  was  observed  over  the  left  hip. 

This  morning  the  child  stands  with  left  limb  advanced, 
toes  slightly  inverted,  and  walks  quite  lame.  The  spinal 
column  presents  no  deviation  laterally  or  antero-posteriorly, 
and  no  tenderness  on  pressure,  percussion,  or  concussion. 
The  left  natis  is  broader  than  its  fellow,  fold  elongated. 
Above  the  trochanter,  and  extending  from  the  same  to  the 
crest  of  the  ilium,  is  a  circumscribed  fulness,  elastic  to  the 
touch,  non-fluctuating,  and  painless  on  pressure.  Thigh 
can  be  flexed  to  an  angle  of  90°  without  pain,  and  can  be 
completely  extended,  though  there  is  muscular  resistance 
to  complete  abduction.  There  is  no  shortening,  no  atrophy 
of  the  limb,  and  no  tenderness  can  be  elicited  at  the  sacro- 
iliac  junction.  The  diagnosis  is  not  positive,  although  hip- 
disease  suspected.  Treatment  expectant,  a  compress  with 
the  roller  being  applied  over  the  tumor  for  the  present. 

On  the  25th  of  January  the  gluteal  tumor  is  perceptibly 
smaller,  and  the  child  walks  with  more  ease. 

A  few  days  later  the  nurse  reports  that  the  patient  com- 
plains of  pain  along  the  spine,  but  a  thorough  examination 
is  attended  with  negative  results. 

By  the  last  of  March  the  tumor  had  extended  below  the 
gluteal  fold;  general  health  very  good. 

Immediately  to  the  left  of  the  sacro-iliac  synchondrosis 
is  a  hardish  movable  tumor,  the  size  of  a  half-walnut;  over 
the  upper  extremity  of  the  thigh  on  a  line  with  the  fold  of 
nates  is  a  tumor  larger  in  size,  fluctuating,  and  painless. 
This  note  was  made  on  the  i6th  of  April. 

Both  tumors  increased  in  size,  the  veins  thereover  became 
very  prominent,  and  an  incision  was  made  in  June,  at  the 
most  dependent  portion,  giving  exit  to  about  one  pint  of 
pus,  of  fair  consistence. 

Constitutional  disturbance  did  not  follow  until  ten  days 
later,  when  the  patient  became  very  feeble  and  indisposed 
to  eat  or  make  any  exertion.  The  discharge  was  very  pro- 
fuse and  offensive.  Brandy  and  tonics  were  given  freely, 
while  the  usual  disinfecting  injections  were  employed. 
The  notes  from  this  time  forward  show  a  steady  decline; 
emaciation  became  extreme,  and  all  efforts,  nutrient  and 
stimulant,  proved  unavailing.  Finally  an  exhaustive  diar- 
rhoea set  in;  this  was  followed  by  a  dysentery,  and  in  August, 
five  days  after  the  diarrhoea  began,  the  patient  died  by 
asthenia. 


COXO-FEMORAL  PERIARTHRITIS.  97 

An  examination,  post-mortem,  revealed  the  sac  of  an  ab- 
scess about  eight  inches  long  by  four  wide,  lying  beneath 
the  gluteal  muscles,  and  a  careful  search  failed  most  signally 
to  detect  any  connection  with  diseased  bone.  The  hip- 
joint,  the  sacro-iliac  joint,  and  the  dorso-lumbar  vertebrae 
were  carefully  examined  and  found  to  be  absolutely  free 
from  disease. 

Ordinarily,  cases  progress  differently  from  the  above  and 
the  explanation  of  this  one  must  be  found  in  the  low  vitality 
of  the  child.  Take,  on  the  contrary,  the  case  of  a  boy  aged 
nine,  who  was  admitted  to  the  hospital  the  first  week  in  Sep- 
tember, 1877,  with  a  history  of  lameness  dating  from  the  igth 
of  August,  he  having  fallen  through  a  cellar  doorway  the 
day  before.  He  had  been  resting  poorly  for  the  past  two 
nights.  On  admission,  tongue  is  coated,  pulse  is  120  tem- 
perature 101.5°,  a°d  tne  boy  is  fairly  nourished.  He  stands 
with  the  right  thigh  advanced,  knee  semiflexed,  and  foot 
slightly  everted;  he  walks  decidedly  lame,  favoring  the 
right  side.  The  natis  is  enlarged,  and  presents  to  the 
touch  an  elastic  feel  just  about  the  trochanter,  where  there 
is  also  considerable  tenderness.  The  surface  temperature 
is  2°  lower  over  this  region  of  fulness  than  at  the  corres- 
ponding point  over  the  right  hip.  There  is  one  inch  in- 
crease in  circumference;  tenderness  in  the  groin,  but  none 
in  the  hip,  as  tested  by  pressure  over  the  trochanter  in  the 
line  of  the  neck  of  the  thigh-bone,  and  by  pressing  on  the 
knee  (flexed)  and  on  the  foot  (leg  extended)  in  the  axis  of 
the  limb.  The  movements  are  limited  in  all  directions — in 
flexion  to  90°,  and  in  extension  to  150°.  There  is  no  spinal 
tenderness,  no  ilio-costal  fulness,  no  tenderness  or  indura- 
tion in  the  iliac  fossa.  On  the  following  evening  a  fly- 
blister  was  applied,  and  the  usual  after-treatment  with 
poultices  was  adhered  to;  yet,  by  the  middle  of  September, 
the  infiltration  had  increased  to  such  an  extent  that  the 
boy  could  scarcely  be  moved,  so  extremely  tender  were  the 
parts  about  the  hip;  the  circumference  had  increased  three 
inches.  From  this  time  forth  it  became  evident  that  sup- 
puration would  supervene,  and  the  parts  ^oon  became 
greatly  distended,  the  thigh  assumed  a  degree  of  flexion 
amounting  to  about  90°,  and  on  the  ist  of  October  there 
was  seven  inches  difference  between  the  two  thighs  at  the 
upper  third.  The  boy  had  become  greatly  reduced.  Ab- 
pcess  opened  by  incision,  and  two  pints  of  pus  evacuated. 
Tonics  and  stimulants  were  administered  quite  freely.  The 


98  DISEASES  OF  THE  HIP, 

case,  without  further  detail,  progressed  to  a  cure  by  the 
loth  of  November,  the  opening  of  the  abscess  having  closed 
two  weeks  after  the  incision.  The  boy  was  discharged  in 
December  completely  restored;  no  lameness,  no  deformity, 
in  good  health.  In  January,  1880,  I  sought  him  out,  and 
made  an  examination  of  the  limb,  finding  a  joint  absolutely 
perfect,  so  far  as  signs  go.  There  was  no  atrophy  of  the 
limb,  no  loss  of  muscular  power.  The  only  sign  of  former 
disease  was  a  cicatrix  on  the  posterior  surface  of  the  thigh 
in  the  upper  third. 

Such  extensive  suppuration  with  so  perfect  a  recovery  is 
somewhat  remarkable,  did  we  not  remember  how  capacious 
is  the  cellular  tissue  under  the  fascia  of  the  thigh.  The 
muscles  are  generally  well  protected  against  injury  and 
one  often  finds  in  bone  disease,  for  instance,  these  immense 
accumulations  of  pus  with  very  little  impairment  of  mus- 
cular tissue.  A  not  uncommon  mode  of  termination,  espe- 
cially in  cases  of  mild  type,  is  by  resolution. 

A  girl,  aged  eight  years,  presented  on  admission  a  well- 
marked  swelling  in  thegluteal  region,  right  side,  with  much 
pain,  extra  heat  and  tenderness.  Her  axillary  temperature 
was  102.6°.  She  could  with  difficulty  walk,  and  the  joint, 
while  not  tender,  was  limited  in  its  movements  by  peri- 
articular  infiltration. 

The  adductors  were  likewise  tense.  Her  symptoms  fol- 
lowed a  fall  against  the  round  of  a  chair  fourteen  days'pre- 
viously,  the  pain  coming  on  the  same  night.  Her  nights 
became  restless,  and  the  case  was  regarded,  so  the  father 
reported,  as  one  of  hip-disease.  The  pain  was  chiefly  re- 
ferred to  the  knee,  and  this,  with  the  signs,  made  the  diag- 
nosis an  extremely  plausible  one.  The  direct  contusion, 
the  speedy  development  of  acute  inflammation,  the  infiltra- 
tion, and  the  absence  of  any  joint-tenderness  enabled  me  to 
diagnosticate  a  periarthritis.  Hot  fomentations  were  em- 
ployed, and  on  the  26th  of  October,  one  month  after  admis- 
sion, resolution  was  progressing  rapidly.  On  the  loth  of 
December  there  was  no  lameness,  no  infiltration,  no  atrophy 
—no  pain.  The  patient  was  discharged,  and  two  years 
afterwards  I  examined  her  again  without  finding  a  symptom 
or  sign  of  disease. 

Glandular  suppuration  in  the  inguinal  region  is  of  longer 
duration  than  when  it  involves  the  cellular  tissue,  but  the 
symptoms  otherwise  differ  only  in  severity  A  girl  aged 
five  years,  was  admitted  in  July,  1876.  There  was  entire  ab- 


COXO-FEMORAL   PERIARTHRITIS.  99 

sence  of  any  cause,  predisposing  or  exciting,  in  the  history. 
The  first  sign,  a  swelling,  appeared  in  the  left  groin  four 
months  before  her  admission.  Lameness  was  first  observed 
about  the  same  time. 

The  patient  on  admission  was  quite  anaemic.  She  stood 
with  left  limb  a  little  advanced,  and  walked  favoring  this 
limb.  When  the  child  was  placed  in  the  dorsal  decubitus  so 
that  the  spinous  processes  were  on  the  same  horizontal 
planes,  the  distance  between  popliteal  space  and  floor  was 
three  inches  ;  flexion  could  be  made  over  the  normal  arc, 
and  abduction  and  adduction  were  easily  accomplished.  The 
thigh  was  one  half  inch  smaller  than  its  fellow  in  the 
left  groin  ;  about  midway  of  Poupart's  ligament  was  an 
indolent  ulcer  three  quarters  of  an  inch  long  by  one  inch 
wide,  edges  smooth  ;  one  inch  below  this  lay  a  smaller  ulcer 
in  the  bottom  of  which  was  a  little  pus.  Suppurative 
lymphadenitis  was  diagnosticated,  and  the  treatment  con- 
sisted of  simple  dressings  and  an  alterative  tonic  with  cod- 
liver  oil.  These  ulcers  proved  very  obstinate,  and  did  not 
thoroughly  heal  until  March  of  the  following  year.  She 
did  not  gain  sufficient  strength,  however,  to  warrant  her  re- 
moval from  treatment ;  but  on  April  27th,  five  weeks  after 
the  closing  of  the  ulcers,  the  child  was  discharged  cured, 
there  being  no  halt  whatever  in  her  gait. 

DIAGNOSIS. — To  differentiate  this  from  ostitis  or  from 
synovial  diseases  we  must  remember  that  bone-disease  es- 
pecially, if  it  be  tuberculous,  is  essentially  chronic,  and  that 
the  pain  and  lameness  always  precede  the  infiltrations  of 
the  soft  parts.  In  this  connection  we  recognize  the  import- 
ance of  a  clear  history,  for  on  this  the  facility  of  diagnosis 
depends.  The  deformity  and  the  locality  of  the  abscess 
furnish  no  diagnostic  signs  of  importance.  In  this,  as  in 
many  other  joint-diseases,  it  is  extremely  difficult  to  diagnos- 
ticate the  case  at  a  single  examination. 

A  female  child,  aged  six  months,  was  brought  to  the  dis- 
pensary department  in  June,  1881.  There  was  a  large 
amount  of  infiltration  in  the  left  groin  and  this  extended 
round  the  upper  third  of  the  thigh,  the  limb  being  rotated 
outward.  I  had  difficulty  in  getting  any  motion  at  the 
joint  by  reason  of  the  apparent  mechanical  obstruction, 
After  a  little  coaxing  I  did  get  smooth  motion  over  limited 
arcs  and  succeeded  in  eliminating  from  my  mind  the  ques- 
tion of  a  diastasis.  True,  I  had  not  elicited  any  history  of 
a  fall  or  injury  of  any  kind,  yet  the  position  of  the  limb,  the 


100  DISEASES  OF  THE  HIP. 

absence  of  redness  of  th'e  integument  naturally  suggested 
such  an  accident.  The  symptoms  were  of  three  weeks' 
duration,  and  the  family  history  was  aught  but  reassuring. 
The  mother  was  one  of  twenty-one  children,  five  of  whom 
only  were  living.  I  could  not  find  any  condylomata,  but 
my  suspicions  of  syphilis  were  so  strong  that  I  made  a 
diagnosis  of  hereditary  syphilitic  periarthritis  and  ordered 
one  twelfth  of  a  grain  of  calomel  three  times  a  day. 

Seven  days  later  the  infiltration  was  much  more  circum- 
scribed, and  fluctuation  was  discovered.  Four  days  after- 
wards I  made  an  incision,  giving  exit  to  a  few  ounces  of 
pus,  and  the  case  progressed  uninterruptedly  to  a  good 
recovery.  Within  a  fortnight  the  functions  of  the  joint 
were  normal,  the  deformity  had  disappeared,  and  a  cure  was 
recorded.  I  took  the  precaution  to  examine  the  parts  a 
month  later,  and  found  no  relaxation  of  the  capsular  liga- 
ment and  no  impairment  whatever  to  the  joint. 

When  there  is  an  absence  of  infiltration,  and  when  one  gets 
a  history  of  a  strain  or  over-exertion  and  an  insidious  lame- 
ness, the  diagnosis  is  much  more  difficult.  In  July,  1880,  Dr. 
Ripley  asked  me  to  see  with  him  a  boy  aged  six  years,  who, 
three  weeks  before  our  visit,  had  an  acute  suppurative 
disease  of  the  middle  ear,  with  perforation  of  the  drum. 
From  this  he  had  made  a  good  temporary  recovery.  One 
week  after  the  beginning  of  his  ear-disease  on  a  damp,  dis- 
agreeable day,  he  had  been  taken  for  a  sail  on  the  East 
river,  and  on  his  return  that  night  he  cried  frequently  during 
sleep.  In  the  morning  there  was  febrile  movement,  with  a 
disposition  to  flex  the  left  thigh  on  pelvis.  Any  attempt  to 
move  the  limb  was  attended  with  sharp  cries  and  the 
mother  fancied  that  the  knee  was  swelled,  but  Dr.  Ripley, 
who  saw  ths  case  next  day,  could  not  find  any  swelling.  He 
did  find  a  temperature  of  104.5°,  anfi  a  corresponding  de- 
gree of  constitutional  disturbance.  The  thigh  could  be 
extended  quite  easily,  but  there  was  resistance  to  abduction. 
The  movements  became  less  free  in  a  few  days,  and  we 
found  the  limb  extended,  while  the  right  was  flexed  and 
adducted,  so  that  the  sole  of  the  foot  pressed  firmly  against 
the  dorsum  of  the  other  foot,  as  if  assisting  in  maintaining 
extension.  There  was  a  distinct  area  of  induration  in  the 
iliac  fossa  glandular,  perhaps,  and  pressure  elicited  tender- 
ness. The  thigh  could  be  easily  extended,  but  flexion  be- 
yond 90°  met  with  resistance  and  caused  pain.  Abduction 
and  rotation  were  likewise  resisted,  while  there  was  entire 


COXO-FEMORAL   PERIARTHRITIS.  IOI 

absence  of  joint  tenderness.  The  fold  of  the  nates  was  a 
little  lower  on  this  side.  Yet  the  gluteal  region  was  free 
from  any  infiltration.  It  was  difficult  to  decide  between  a 
periarthritis,  and  an  acute  bone  lesion.  Yet  the  history  and 
the  appreciable  infiltration  so  speedily  developed,  pointed 
to  the  former,  and  this  diagnosis  was  recorded.  Counter- 
irritation  was  advised,  and  on  my  next  examination,  eleven 
days  afterwards,  the  signs  were  less  marked  and  the  diag- 
nosis was  in  a  measure  confirmed. 

Dr.  Ripley  informs  me  that  the  case  terminated  in  a 
cure. 

Pelvic  cellutitis  in  a  child  is  not  of  common  occurrence, 
yet  when  it  does  occur  the  symptoms  and  signs,  too,  are 
those  of  a  periarthritis;  indeed,  it  is  a  periarthritis.  The 
iliac  fossa  is  the  point  of  departure,  and  the  ilio-psoas  mus- 
cle is  in  spasm  by  reason  of  the  infiltration  thereabout. 

About  the  middle  of  September,  1882,  a  little  girl,  two 
and  a  half  years  of  age,  was  brought  to  me  for  a  hip  lesion 
of  two  weeks'  standing.  The  process  began  acutely,  and 
on  the  day  I  examined  the  case  the  right  hip  was  held  in 
sharp  flexion,  and  there  was  a  perceptible  amount  of  infil- 
tration in  the  groin  and  extra  heat  and  tenderness  along 
the  inner  side  of  the  thigh.  I  made  out  a  periarthritis, 
the  lesion  being  chiefly  confined  to  the  internal  iliac  fossa, 
and  the  case  subsequently  came  under  the  care  of  Dr.  Shaf- 
fer, who  confirmed  the  diagnosis  I  had  made.  The  case 
went  on  to  suppuration,  and  on  the  disappearance  of  the 
infiltration  the  deformity  disappeared,  and  soon  the  patient 
was  discharged  cured. 

On  the  right  side  one  naturally  thinks  of  a  perityphlitis, 
and  the  signs  of  an  idiopathic  perityphlitis  are  not  unlike 
those  of  a  pure  periarthritis  wherein  the  psoas  group  is 
chiefly  involved. 

A  periarthritis  occurring  in  a  neurotic  subject  is  not 
always  easily  diagnosticated.  The  neuroses  obscure  symp- 
toms, and  we  can  rely  only  on  signs.  And  thus,  too,  if 
malarial  symptoms  enter  as  a  complication  the  difficulty  in 
arriving  at  a  correct  diagnosis  is  certainly  very  great.  I 
am  reminded  now  of  a  case  that  puzzled  me  for  two  or 
»three  weeks,  and  it  is  only  on  a  careful  review  of  the  symp- 
toms that  I  can  find  any  consolation  in  having  erred  so 
egregiously.  The  patient  was  a  sickly,  cadaveric-looking 
girl  nine  years  of  age  from  \Ve_stchester  county,  and  came 
under  my  observation  in  th  latter  part  of  March,  1881.  She 


102  DISEASES  OF  THE  HIP. 

had  always  been  the  delicate  one  of  a  phthisical  family  In 
the  preceding  year  she  had  suffered  much  from  malarial 
fever.  Two  weeks  prior  to  my  first  record  of  her  case,  the 
girl  had  a  chill  one  night,  and  this  was  followed  by  fever. 
Next  day  she  favored  the  left  hip  in  walking,  and  the 
lameness  continued  without  abatement;  indeed,  it  had  been 
steadily  increasing.  There  was  also  much  pain  in  the  outer 
side  of  the  thigh,  and  in  the  vicinity  of  the  hip.  The  child 
was  worse  by  night  and  comparatively  well  by  day,  and 
febrile  movement  had  been  quite  marked  at  irregular  inter- 
vals. When  I  made  my  examination  I  found  that  I  could 
not  abduct  the  right  hip  to  my  satisfaction,  and  that  rota- 
tion caused  a  little  pain.  Other  movements  were  perfect. 
The  same  signs,  identically,  were  found  on  testing  the  func- 
tions of  the  left  hip,  and  in  addition  there  was  marked  ten- 
derness and  a  shade  of  fulness  behind  the  trochanter. 
The  spinous  processes  were  very  tender,  and  in  fact  the 
whole  body  was  markedly  hyperaesthetic.  The  pain  was 
referred  to  the  left  lower  extremity  a  few  days  later,  and  a 
thorough  examination  could  not  be  had  on  account  of  the 
extreme  tenderness.  I  was  at  a  loss  to  make  a  diagnosis, 
but  felt  quite  sure  that  a  malarial  element  was  present  and 
that  this  might  account  for  the  spinal  neuroses. 

Quinine  was  pushed  to  physiological  effects,  and  within 
a  week  all  spinal  tenderness  had  disappeared.  The  tender- 
ness about  the  hip  remained,  however.  Then  I  left  off  the 
quinine  for  a  week  and  the  neuroses  returned.  On  resum- 
ing the  quinine  the  complications  gave  place  to  the  real  hip 
symptoms,  and  by  this  time,  twenty  days  after  admission,. 
there  was  an  unmistakable  area  of  fluctuation  over  and 
above  the  trochanUr.  In  less  than  a  fortnight  an  immense 
abscess,  involving  the  whole  of  the  upper  two  thirds  of  the 
thigh  was  opened  and  the  flow  of  pus  was  quite  remarkable. 

It  was  not  until  the  end  of  August  that  the  case  was  pro- 
nounced cured.  The  neuroses  by  this  time  had  long  since 
ceased  to  annoy,  the  functions  of  the  hip  were  perfect,  and 
the  girl  had  grown  plump  and  hearty.  Recently,  two  years 
from  that  date,  I  have  seen  my  old  patient,  and  have  failed 
to  find  any  traces,  save  the  superficial  cicatrices,  of  the  for- 
mer disease.  It  all  seems  clear  to  me  now,  and  my  only 
wonder  is  that  I  did  not  make  out  a  pure  neurosis  of  the 
hip. 

There  was,  then,  the  case  as  it  stood,  viz.:  a  periarticular 
celluhtis  occurring  in  a  neurotic  subject  in  whom  malarial 


COXO-FEMORAL  PERIARTHRITIS.  103 

poisoning  was  present.  Let  one  remember,  then,  in  making 
a  differential  diagnosis,  that  the  following  points  are  to  be 
considered: 

1.  There  may  be  simply  a  sprain  or  contusion. 

2.  There  may  be  a  bursitis   simply,  and  a  knowledge  of 
the  locality  of  the  bursa  will  assist  materially  in  arriving 
at  a  conclusion. 

3.  An  exacerbation  in  a  very  slow  and  scarcely  appreci- 
able case  of  chronic  ostitis  may  closely  resemble  a  periar- 
thritis. 

4.  A  neurosis  from  any  cause,  with  muscular  contraction, 
may  be  taken  into  consideration. 

5.  A  residual  abscess  from  lumbar  Pott's  disease  may 
present  beneath  the  fascia.     The  spine  should  always  be 
examined. 

6.  An  acute  epiphysitis  may  give  rise  to  signs  that  will 
be  very  confusing. 

The  diagnosis,  as  above  remarked,  becomes  comparatively 
easy  when  one  takes  into  account  the  behavior  of  acute  and 
chronic  inflammation. 

The  prognosis  is  good,  that  is,  a  cure  can  be  predicted  in 
from  three  weeks  to  six  months.  The  deep  abscess  of 'the 
thigh,  however,  is  a  more  serious  affection,  and  it  is  in  such 
that  a  fatal  issue  is  sometimes  to  be  expected.  It  is  ex- 
tremely rare  that  joint-disease  follows  such  an  inflammation, 
and  hence  one  can  safely  assure  the  patient  that  no  injury 
to  the  articulation  will  ensue.  I  deem  it  my  duty,  however, 
to  place  on  record  this  exceptional  case. 

The  patient  was  a  boy  aged  three  and  a  half  years  when 
I  first  saw  him  in  March,  1882.  He  came  with  a  history  of 
a  fall  from  a  high  chair  six  months  previously,  getting 
a  sharp  contusion  over  the  upper  and  outer  aspect  of  the 
right  thigh.  He  suffered  much  the  same  night,  and  was 
confined  to  bed  by  order  of  the  physician  who  had  been 
called,  for  three  weeks,  the  contusion  slowly  giving  way  to 
a  circumscribed  swelling.  This  soon  terminated  in  abcess, 
which  was  opened  and  the  discharge  therefrom  continued 
in  varying  degree  up  to^the  date  of  his  appearance  at  the 
hospital.  The  lameness  was  very  slight,  in  fact  it  was  with 
difficulty  recognized;  the  limbs  were  parallel  ;  there  was  no 
atrophy,  no  shortening.  The  joint  surfaces  were  smooth 
and  free  from  tenderness,  and  the  movements  were  very 
slightly  if  at  all  limited  in  any  direction.  The  sinus  com- 
municated with  a  sac  lying  beneath  the  fascia  lata,  but  no 


104  DISEASES  OF  THE  HIP. 

bone  could  be  discovered  by  careful  probing.  A  diagnosis 
of  periarthritis  was  made,  and  the  case  continued  under 
the  care  of  Dr.  Mayer,  with  whom  I  had  simply  consulted. 

Everything  progressed  to  a  wish  until  the  latter  end  of 
December,  same  year.  The  doctor  gave  most  encouraging 
reports  of  the  case  ;  the  lameness  was  for  months  not  per- 
ceptible, but  the  sac,  which  had  been  well  cleansed  from 
time  to  time,  would  occasionally  refill,  and  on  these  occa- 
sions the  child  would  favor  the  limb.  Finally  Dr.  Mayer 
lost  sight  of  the  case.  The  parents  moved  to  another  part 
of  the  city,  the  patient  suffered  from  unavoidable  neglect, 
and  when  I  saw  him  again  in  February  of  this  year  the  signs 
pointed  to  a  well-marked  case  of  chronic  periosto-ostitis  of 
the  hip.  Deformity  had  already  become  a  prominent  sign, 
and  at  the  mother's  request  he  was  admitted  to  the  hos- 
pital. Under  a  better  hygiene  and  a  modified  rest  he  soon 
showed  decided  improvement,  but  the  separation  was  so 
poorly  borne  by  the  mother  that  she  insisted  on  removing 
him  a  few  days  after  admission. 

Dr.  Cheever,  of  Boston,  in  a  very  interesting  paper  in 
the  Boston  Medical  aud  Surgical  Journal  for  April  12, 
1883,  gives  some  cases  in  his  own  experience  wherein  in- 
flammation beneath  the  deep  fascia  of  the  thigh  led  to  un- 
pleasant consequences.  I  have  myself  seen  cases  of  deep 
subfascial  abscess  both  in  front  of  and  behind  the  hip,  run- 
ning an  extremely  tedious  course  and  leading  one  to  suspect 
bone  disease  as  the  initial  lesion.  Careful  exploration, 
however,  fails  to  detect  any  necrotic  bone.  It  is  certainly 
the  experience  of  many  surgeons,  whose  field  is  large,  to 
find  burrowing  pus  sacs  with  fungous  lining  membranes, 
to  thoroughly  open  the  same  and  to  find  no  diseased  bone. 

A  well-developed  lad,  thirteen  years  of  age,  came  under 
treatment  in  March,  1882,  for  what  I  regarded  with  some 
reservation  a  strain  of  the  right  hip.  The  only  signs  I 
could  find  on  a  pretty  thorough  examination  were  a  little 
resistance  on  abduction,  and  when  the  thigh  was  forced  in 
this  direction,  pain  was  complained  of  in  the  capsule  (?)  of 
the  joint.  After  a  long  run  on  th£  first  day  of  December, 
1881,  he  felt  stiff  next  morning,  and  walked  lame.  Pain  at 
this  time  was  referred  to  the  groin,  and  gluteal  region. 
These  symptoms  continued  a  fortnight,  and  after  ten  days 
of  complete  remission  returned  and  were  pretty  constant 
up  to  the  date  he  presented  for  treatment.  Ten  days  after 
his  first  visit  in  March  I  found  decided  tenderness  over 


COXO-FEMORAL  PERIARTHRITIS.  10$ 

the  posterior  superior  spinous  process  of  the  ileum,  and 
ordered  a  blister. 

Fourteen  months  elapsed  before  I  had  an  opportunity  of 
seeing  the  case  again.  This  was  in  May  of  the  present 
year,  and  in  March  an  abcess  had  appeared  spontaneously 
near  the  right  sacro-iliac  junction.  An  immense  sac  lying 
under  the  gluteal  muscles,  and  filling  about  all  of  the  exter- 
nal iliac  fossa,  was  explored  with  much  care,  and  I  could 
not  find  any  evidences  of  diseased  bone. 

There  was  no  tenderness  at  either  sacro-iliac  or  hip  joint, 
the  lameness  was  so  slight  as  to  be  scarcely  appreciable. 
The  inguinal  glands  were  enlarged,  and  there  was  addi- 
tional fullness  in  this  locality  without  any  fluctuation. 

The  sac  had  been  washed  out  daily,  and  the  discharge  had 
varied  in  quantity.  The  fullness  in  groin  has  increased,  and 
has  caused  considerable  uneasiness.  In  August  I  find  a 
little  fluctuation  in  Scarpa's  space,  with  one  or  two  points  of 
redness  and  induration.  The  gluteal  sac  is  discharging  very 
little.  Dr.  Wm.  T.  Bull  saw  the  case,  explored  the  sac  and 
failed  to  find  diseased  bone  ;  yet  he  is  quite  confident 
that  such  exists.  There  is  very  little  doubt  that  the  pus 
is  burrowing  down  into  Scarpa's  space,  and  appropriate  sur- 
gical measures  have  already  been  urged.* 

This  case  furnishes  not  only  many  points  of  interest  to 
the  diagnostitian,  but,  illustrates  the  importance  of  prompt 
surgical  interference.  This  immense  sac,  in  such  close 
proximity  to  the  joint,  is  certainly  a  dangerous  neighbor,  and 
the  sooner  it  can  be  removed  the  better  it  will  be  for  the 
joint;  the  better  it  will  be  for  the  health  of  the  patient.  I 
have  grown  extremely  restive  under  chronic  abscesses 
arising  in  tissues  around  the  joint.  It  is  dangerous  con- 
servatism to  let  them  alone. 

It  is  regarded  by  some  of  the  more  conspicuously  con- 
servative dangerous  to  probe  sinuses  or  explore  sacs.  I 
am  convinced  by  overwhelming  evidence  that  is  better  to 
make  a  diagnosis,  even  at  the  expense  of  injuring  soft  parts. 
Wounds  will  heal  if  properly  treated,  and  they  will  heal  if 
not  treated,  but  sinuses  will  not  heal  where  they  must  serve 
as  tracks  for  the  passage  of  pus  that  is  being  continually 


*  As  these  sheets  are  going  to  press  Dr.  Bull  writes  me  that  he  has 
this  day,  August  3ist,  at  St.  Luke's,  made  free  incisions  antiseptically  to 
find  a  sequestrum  of  bone  in  the  crest  of  the  ilium  near  posterior  superior 
spinous  process.  His  prognosis  is  good. 


106  DISEASES  OF  THE  HIP. 

manufactured  by  a  pyogenic  membrane.  The  well  is  being 
fed  all  the  while,  and  it  must  have  an  outlet. 

The  following  simple  case  taught  me,  as  a  sad  experience 
will  always  teach,  the  value  of  exploring  sacs,  and  of  omit- 
ting no  recognized  tests  in  arriving  at  a  diagnosis. 

In  the  early  spring  of  1875,  a  female  child,  aged  one  and 
a  half  years,  was  brought  into  the  office  of  the  Out-patient 
Department,  and  the  examination,  which  was  very  superfi- 
cial, resulted  in  a  diagnosis  of  caries  at  the  sacro-iliac 
junction.  The  child  was  feeble,  and  was  with  difficulty 
handled,  on  account  of  tenderness;  the  soft  parts  about 
the  sacrum  were  extensively  infiltrated,  two  or  three  ill- 
conditioned  ulcers  were  present,  and  the  skin  around  these 
was  bluish,  the  veins  were  prominent,  and  there  was  a  sero- 
purulent  discharge  which  was  rather  abundant.  I  did  not 
explore  the  ulcers  and  sinuses  with  a  probe,  nor  did  I  go 
through  with  any  of  the  recognized  tests  for  the  presence 
of  disease  at  the  sacro-iliac  synchondrosis.  I  learned  from 
the  mother  that  this  condition  of  the  soft  parts  had  existed 
for  six  weeks,  and  that  the  first  sign  she  observed  was  a 
small  point  of  redness  and  swelling,  like  an  ordinary  boil. 
She  knew  of  no  cause.  I  did  not  ask  her  anything  about 
previous  treatment — was  hurried,  and,  as  before  stated, 
did  not  examine  very  closely  into  the  case.  It  seemed  clear 
enough  to  me  at  that  time,  for  I  thought  sacro-iliac  disease 
of  common  occurrence.  I  had  not  seen  any  cases  about 
which  I  had  felt  sure  as  to  diagnosis,  yet  I  attributed  this 
to  my  ill-luck.  Simple  dressings,  with  tonics  and  occasion- 
ally stimulants,  made  up  the  treatment  for  the  next  six 
months.  I  did  not  see  the  child  often,  yet  there  seemed  to 
be  no  marked  change  in  the  signs  presenting  from  time  to 
time,  and  while  the  health  was  improving  a  little  I  felt 
no  great  uneasiness  about  the  ultimate  result.  In  September 
she  suffered  considerable^pain,  and  there  were  four  sinuses, 
with  large  openings,  amounting  to  ulcers.  The  mother 
calls  September  i8th  with  the  child,  and  brings  in  her 
hand  a  piece  of  muslin,  one  iuch  square,  which  she  found 
yesterday  protuding  from  one  of  the  ulcers.  The  muslin 
was  far  on  the  way  to  decay,  and,  on  questioning  the 
mother,  she  remembered  well  that,  in  the  early  part  of 
February,  seven  months  before,  the  doctor  who  opened  the 
"  boil"  inserted  a  piece  of  muslin  to  keep  the  wound  open. 
She  did  not  see  the  doctor  any  more,  and  had  forgotten 
allabout  the  tent.  All  the  sinuses  closed  within  a  week, 


COXO-FEMORAL  PERIARTHRITIS.  IO? 

and  the  child  soon  recovered.  I  did  not  see  the  case 
any  more,  but  found  the  child  in  January,  1880,  and  made  a 
careful  examination.  I  did  not  find  any  impairment  of  the 
functions  at  either  hip  or  sacro-iliac  joint.  There  was  no 
atrophy,  save  about  the  cicatrices  which  covered  the  sacral 
region.  The  mother  reported  that  no  relapse  had  ever  oc- 
curred. 

With  the  cases  I  have  recorded  in  connection  with  that 
part  of  my  subject  which  treats  of  the  pathology  and 
clinical  history,  the  transition  to  treatment  is  very  easy. 

TREATMENT. — In  no  one  of  the  inflammatory  lesions  in 
and  about  the  hip  is  there  greater  call  for  the  employment 
of  correct  surgical  principles.  We  seldom  have  a  cold  ab- 
cess  in  periarthritis,  and  hence  the  inflammatory  products 
can  be  treated  without  delay.  In  severe  contusions  rest 
and  hot  or  cold  applications  are  called  for,  as  the  physician's 
choice  may  be.  My  own  preference  is  for  hot  fomentations, 
and  by  hot  fomentations  I  do  not  mean  the  application  of 
a  bit  of  flannel  wrung  out  of  hot  water:  I  mean  more  than 
this.  The  ordinary  toweling  or  spread  cloth  used  for  coun- 
terpanes, should  be  folded  into  several  thicknesses,  satu- 
rated with  water  heated  to  the  boiling  point,  and  deprived 
of  its  superfluous  water  by  wringing.  Then  apply  immedi- 
ately the  cloth  thus  prepared;  quickly  cover  this  with  oil- 
silk  or  oil-muslin,  and  over  all  apply  a  bandage  of  dry  cloth. 
Cloths,  when  properly  applied,  (and  it  will  require  several 
applications  for  one  to  get  familiar  with  all  the  details), 
will  keep  the  parts  hot  for  at  least  twelve  hours.  This  re- 
peated, then,  in  twelve  or  twenty-four  hours,  serves  to  allay 
the  pain  very  often  in  a  remarkably  short  space  of  time. 
If  abscess  form,  the  pus  should  be  promptly  evacuated.  I 
well  remember  a  case  in  which  this  was  delayed,  until  the 
sac  grew  to  immense  size.  It  was  in  a  poorly  nourished 
girl,  four  years  of  age,  whom  I  saw  first  in  August,  1881. 
She  had  never  been  in  good  health,  having  suffered  not  only 
from  many  of  the  exanthemata,  but  from  many  of  their  se- 
quelae. A  week  prior  to  this  visit,  the  mother  heard  her 
complaining  of  the  back.  On  examination,  I  found  the 
little  patient  unable  to  walk  without  a  stiffness  of  .gait.  The 
right  natis  was  a  little  flattened,  and  deep  beneath  the  glu- 
teal  muscles  could  be  felt  a  tumor  filling  the  external  iliac 
fossa,  tender  and  semi-elastic.  In  the  dorsal  decubitus,  the 
left  thigh  could  be  extended  completely,  but  abduction 
was  resisted  and  painful.  Rotation  was  perfect,  and  the 


108  DISEASES  OF  THE  HIP. 

existence  of  any  joint-tenderness  was  extremely  doubtful. 
There  was  no  tenderness  at  the  sacro-iliac  junction. 

I  made  a  diagnosis  of  periarthritis  and  advised  an  inci- 
sion. The  advice  was  not  accepted  by  the  attending  sur- 
geon. Two  and  a  half  months  later  I  saw  the  case  again, 
and  at  that  time  the  abscess  extended  throughout  the  whole 
of  the  gluteal  region.  It  opened  spontaneously;  extensive 
sloughing  followed,  and  the  patient  finally,  in  an  extreme 
degree  of  emaciation,  found  a  home  in  one  of  the  sea-side 
sanitariums.  She  died  of  exhaustion  a  year  after  the  first 
appearance  of  the  disease.  I  am  quite  sure  that  no  signs 
of  disease  in  spine,  sacrum  or  hip  ever  developed  during  the 
whole  course  of  the  illness. 

A  case  in  an  adult  excited  considerable  interest  in  one  or 
two  hospitals  in  the  winter  of  1881. 

A  woman,  twenty-five  years  of  age,  came  to  me  in  Septem- 
ber of  that  year,  and  presented  a  glandular  enlargement  in 
the  inguinal  region,  left  side,  and  a  small  soft  tumor  near 
the  sacro-iliac  synchondrosis,  same  side.  There  were  also 
associated  with  this  condition  occasional  neuralgic  pains. 
The  first  symptoms  began  three  years  before  this  period  as 
she  was  convalescing  from  a  difficult  labor.  A  fall  nearly 
a  year  subsequently  seemed  to  aggravate  the  symptoms. 
In  other  words,  the  whole  history  pointed  toward  a  chronic 
cellulitis  in  the  left  side  of  the  pelvis,  and  she  had  come  to 
the  hospital  on  account  of  some  impairment  to  the  func- 
tions of  the  hip.  It  did  not  require  an  extended  examina- 
tion to  exclude  disease  at  this  articulation,  and  I  referred 
her  to  a  general  hospital.  She  was  admitted  and  examined 
by  the  visiting  physician,  who  referred  her  back  to  me  for 
a  truss.  I  certainly  made  out  a  tumor  in  Scarpa's  space, 
and  got  an  impulse,  but  it  was  the  impulse  of  fluid,  and  I 
declined  to  apply  a  truss.  The  case  was  referred  then  to 
Dr.  Ripley,  who  agreed  with  me  in  diagnosticating  a  pelvic 
abscess.  ^  Pressure  on  the  sacral  tumor  would  impart  an 
impulse  in  the  tumor  in  Scarpa's  space.  Under  expectant 
treatment  both  of  them  increased  rather  rapidly  in  size, 
and  Dr.  Ripley  admitted  her  into  St.  Francis  Hospital  in 
the  early  part  of  June,  1881,  for  operation.  The  aspirator 
was  first  employed,  and  shortly  afterwards  small  ulcers 
formed.  Then  a  free  incision  was  made  and  the  upper 
tumor  collapsed.  Through  drainage  was  established  and 
repair  promptly  followed.  At  no  time  was.  there  any 
eroded  bone  found,  and  it  was  the  general  opinion  that  the 


COXOFEMORAL  PERIARTHRITIS.  109 

abscess  did  not  depend  on  caries,  or  in  fact  on  any  bone 
lesion. 

When  the  periarthritis  is  glandular  the  surgical  princi- 
ples apply  here  as  well  as  in  other  tissues.  Glandular  ab- 
scesses, however,  as  a  rule  give  very  little  cause  for  anxiety. 
The  great  danger  in  allowing  any  inflammatory  tissues  to 
remain  long  in  contiguity  to  so  important  an  articulation 
must  be  quite  apparent.  Orthopedic  appliances  are  very 
seldom  called  for,  and  one  need  not  attach  any  importance 
to  the  deformities  which  often  arise  during  the  progress  of 
the  disease.  In  closing  this  chapter  I  can  name  nothing 
more  important  in  the  treatment  than  a  correct  diagnosis. 


CHAPTER    VII. 
BURSITIS  OF  THE  HIP. 

From  the  anatomy  of  the  hip  one  will  learn  that  several 
bursae  exist  about  this  joint  and  contribute  largely  to  the 
smoothness  with  which  the  muscles,  in  their  action,  pass 
over  bony  prominences.  Their  functions  have  already  been 
discussed  in  the  chapter  on  anatomy,  and  now  we  discuss 
them  in  a  state  of  inflammation.  Many  believe  that  one  of 
the  modes  of  origin  of  hip-joint  disease  is  through  injury 
and  consequent  disease  of  the  bursae,  and  a  tumor  pre- 
senting in  the  gluteal  region,  for  instance,  in  the  second 
stage  of  a  chronic  articular  ostitis  is  often  pointed  out  as 
simply  a  bursitis.  Now  this  is  very  confusing,  and  in  my 
own  experience  I  have  really  come  in  contact  with  very 
few  cases  of  unmistakable  primary  bursitis  in  connection 
with  the  hip-joint,  and  in  the  text-books  I  do  not  find  any 
cases  recorded  with  a  generosity  that  will  enable  one  to 
make  the  diagnosis  for  himself.  The  general  practitioner, 
it  would  seem,  is  in  a  position  to  recognize  these  lesions 
in  the  early  stage  by  very  simple  methods,  and  this  being 
done,  many  cases  may  not  only  be  saved  from  joint-dis- 
ease, but  from  the  prolonged  treatment  for  a  joint  disease 
which  has  no  existence  in  fact. 

Those  most  commonly  the  seat  of  inflammation  are;  the 
bursa  under  the  glutei  lying  over  the  pyriformis,  the  bursa 
in  front  of  the  gluteus  maximus,  and  between  it  and  the 
vastus  externus,  and  the  large  bursa  between  the  ilio-psoas 
and  the  capsule  of  the  joint  (see  Figs,  i  and  2).  Others  may, 
and  I  presume  do,  become  inflamed  under  the  influence  of 
pressure  or  blows,  and  yet  they  are  so  intimately  associated 
with  neighboring  tissues  that  the  recognition  of  them  as 
individual  pathological  entities  is  next  to  impossible,  and 
to  define  them  as  such  would  subject  one  to  the  charge  of 
striving  after  "pathological  refinements."  The  cause  is 
manifold.  Bursitis  frequently  follows  very  closely  a  fall 
or  a  strain,  is  often  induced  by  exposure  to  cold,  and  occa- 


BURSITIS  OF  THE  HIP.  Ill 

sionally  we  have  to  admit  that  it  is  idiopathic.     It  matters 
little,  however,  what  the  cause  may  be.     It  is  sufficient  to' 
know  that  a  strumous  bursitis  is  not  recognized. 

In  1874  there  came  under  my  observation  a  lad,  aged 
fourteen  years,  with  pains  about  his  left  hip  and  tender- 
ness over  the  upper  portion  of  the  shaft.  The  case  puz- 
zled me  considerably  then,  and  finally  I  concluded  it  must 
be  a  peculiar  form  of  "  hip-disease."  I  saw  him  from  time 
to  time,  at  long  intervals,  until  1877,  when  I  made  a  diag- 
nosis of  periostitis.  At  that  time  he  was  unable  to  lie  on 
the  left  side,  and  yet  I  could  not  detect  any  lameness  or 
any  marked  impairment  of  joint  function.  He  gave  the 
history  of  exacerbations  of  pain,  confined  chiefly  to  the 
upper  portion  of  the  thigh,  and  generally  relieved  by  iodine 
topically  employed. 

I  could  not  find  a  record  of  any  notes  of  his  case  in  1874, 
but  I  remembered  him  very  well,  and  remembered  how 
barren  of  any  tangible  symptoms  my  observations  had 
been. 

On  the  5th  of  March,  1879,  I  saw  him  again,  after  a 
long  absence,  and  I  could  detect  no  real  difference  between 
the  hip  functions  at  that  time  and  those  in  1877.  He  re- 
ported that  he  had  much  pain — not  enough,  however,  to 
prevent  him  from  working — and  had  not  been  able  to  lie 
on  his  left  side  with  any  comfort  for  six  months.  The 
fulness  and  tenderness  about  the  trochanter  were  still 
present;  but  it  did  not  occur  to  me  until  December 
3d  of  that  year  (1879)  that  this  must  be  a  case  of  recur- 
ring bursitis,  and  on  examining  the  parts  more  carefully,  I 
could  make  out  quite  distinctly,  by  palpation,  a  small  cyst 
occupying  the  proper  site  of  the  bursa  which  lies  under  the 
gluteus  maximus  and  upon  the  trochanter  (see  Fig.  2,  C). 

On  the  introduction  of  the  needle  of  a  hypodermic 
syringe  a  synovial  like  fluid  was  removed,  and  the  cyst  col- 
lapsed. The  case  seemed  clear  enough  then,  and  the  ex- 
acerbations of  pain  and  tenderness  he  had  had  for  the  past 
five  or  six  years  were  easily  explained  by  the  filling  and 
refilling  of  the  bursal  sac,  consequent  on  strains  or  bruises. 
A  few  days  later  my  diagnosis  was  fully  confirmed  by  Dr. 
J.  H.  Ripley.  The  contents  were  thoroughly  removed  by  a 
hypodermic  syringe,  and  a  compress  was  applied.  This 
gave  temporary  relief,  and  he  came  under  treatment  again 
in  March,  1880. 

The  further  progress  of  the  case  has  been,  on  the  whole, 


H2  DISEASES  OF  THE  HIP. 

satisfactory.  The  removal  of  the  sac  by  operation  was  not 
practicable  and  was  not  urged,  because  of  his  inability 
to  spare  the  time,  and  because  blisters  would  give  relief 
whenever  a  re-accumulation  of  serum  took  place.  He  has 
experienced  very  little  inconvenience  since  the  nature  of  the 
disease  has  been  recognized.  The  thigh  is  an  inch  smaller 
in  circumference  than  its  fellow,  but  there  is  no  lameness 
and  no  pain.  I  have  recently  examined  him,  and  a  cure  is 
pretty  well  established. 

Here  then,  we  have  no  account  of  any  direct  blow  or 
strain  to  induce  the  bursitis  in  the  first  instance,  but  it 
does  not  seem  fair  to  exclude  such  a  cause,  inasmuch  as 
no  history  of  the  case,  in  the  early  part  of  its  course  was, 
if  obtained,  ever  recorded. 

This  is  unlike,  in  duration  at  least,  the  case  of  a  stout, 
hearty-looking  girl,  nine  years  of  age,  who  was  admitted  to 
the  hospital  on  the  4th  of  March,  1880,  bearing  from  the 
family  physician  a  written  diagnosis  of  hip-disease.  We 
could  not  detect  any  flaw  in  family  or  personal  history,  and 
could  not  trace  her  lameness — of  four  weeks'  duration 
only — to  any  distinct  trauma,  although  it  was  presumed 
that  she  had  strained  her  hip  while  at  play,  as  she  was  very 
active,  and  during  her  waking  hours  nearly  all  the  time  on 
her  feet. 

With  the  lameness  there  came  also  an  occasional  pain 
in  the  knee,  and  an  unusual  sense  of  fatigue  after  playing 
all  day. 

On  examination  I  found  that  she  stood  squarely  on  both 
feet  with  limbs  parallel,  and  that  she  walked  with  great  ease, 
though  favoring  the  right  limb  perceptibly.  I  could  see 
a  protrusion  of  the  soft  parts  in  the  gluteal  region,  which 
on  palpation  could  be  made  out  as  a  cyst-like  body  about 
the  shape  and  size  of  a  hen's  egg,  lying  deep  under  the 
gluteal  muscles,  not  tender  on  pretty  rough  handling,  and 
not  giving  rise  to  any  glandular  enlargement  in  the  inguinal 
region. 

I  could  not  detect  any  joint  tenderness,  or  bony  tender- 
ness, and  could  not  find  any  resistance  whatever  to  any  of 
the  normal  joint  movements,  unless,  perhaps,  there  was 
slight  reflex  muscular  spasm  on  extreme  abduction.  There 
was  no  atrophy  of  the  limb,  and  no  tenderness,  pain  or  in- 
filtration in  iliac  fossa  or  ilio-costal  space. 

The  diagnosis  of  bursitis  was  made  without  any  reserva- 
tion, and  the  treatment  to  be  employed  was  blistering  and 


BURSITIS  OF  THE  HIP.  113 

poulticing.  Three  blisters  were  applied  within  the  next 
two  months,  and  there  was  no  marked  diminution  in  size 
of  the  bursal  tumor.  In  the  absence  of  any  acute  symp- 
toms the  patient  was  discharged  in  June  and  continued 
under  treatment  in  the  out-door  department.  A  compress 
and  the  spica  bandage  were  used,  and  by  September  3d  it 
was  extremely  difficult  to  detect  any  fulness  whatever  in 
the  gluteal  region.  There  were  absolutely  no  hip  signs, 
and  the  patient  was  discharged  cured. 

Occasionally  one  finds  a  peculiar  "click"  on  manipulat- 
ing joints,  and  the  interpretation  of  this  sign  is  attended 
with  much  difficulty.  My  own  impression  is  that  the 
click  is  produced  by  the  slipping  of  a  muscle  or  tendon 
over  a  bursa  formerly  the  seat  of  inflammation  and  now 
roughened,  more  or  less,  by  the  resulting  diminution  in 
secretion.  When  it  occurs  within  a  joint  its  significance  is 
easier  of  explanation.  While  examining  a  highly  neurotic 
patient  during  the  past  winter,  I  met  with  this  phenomenon, 
and  it  seemed  to  me  that  its  location  was  within  the  pelvic 
cavity,  or,  at  least,  near  the  pubic  rim.  The  case  was  one 
of  sciatica,  and  in  the  absence  of  any  joint  symptoms,  I 
concluded  that  the  bursa  under  the  ilio-psoas  was  at  fault 
as  I  invariably  got  the  "  click  "  when  that  muscle  was  sub- 
jected to  traction. 

A  case  of  very  great  interest,  diagnostically  considered, 
was  brought  to  me  by  Dr.  Martin,  of  Boston,  a  member 
of  my  class  at  the  Polyclinic,  in  April  of  the  present 
year.  It  was  a  lady  thirty  years  of  age,  who  complained 
of  a  sense  of  fatigue  and  a  peculiar  "  click,"  which  she 
experienced  on  walking.  It  was  felt  near  the  insertion 
of,. the  gluteus  maximum,  right  side,  and  I  tried  in  vain 
to  get  it  by  passive  motion.  In  the  recumbent  or  upright 
posture  she  was  unable  to  produce  it,  no  matter  into 
what  position  she  threw  the  limb,  but  let  her  walk  across 
the  floor,  and  with  my  hand  over  the  region  in  question 
I  could  appreciate  the  "  click"  quite  distinctly.  There 
was  no  arthropathy  and  no  interference  whatever  with  the 
nutrition  of  the  limb.  There  was  no  swelling  and  no  ten- 
derness. Three  months  before  the  date  of  my  examination 
it  had  appeared  quite  unaccountably.  My  opinion,  as 
given  the  Doctor,  was  that  the  bursa  over  the  trochanter 
had  been  impaired  by  inflammatory  changes.  Dr.  Shaffer 
met  with  the  "  click  "  in  a  case  of  true  neuromimesis  of  the 
knee-joint,  which  he  reports  in  his  monograph,  and  I  infer 


114  DISEASES  OF  THE   HIP. 

lhat  it  was  'periarticular  from  his  explanation,  viz.:  It  was 
clue  to  "the  reduction  of  a  temporarily  displaced  tendon, 
or  perhaps  to  the  reduction  of  a  slight  subluxation;  in 
either  event  caused  by  muscular  action."  The  tendon  pass- 
ing over  a  bony  prominence  not  covered  by  a  bursa  whose 
functions  are  normal,  explains  to  my  own  mind  this  con- 
dition of  things. 

The  symptoms,  then,  seem  sufficiently  pronounced  to  give 
a  clinical  picture  that  should  enable  one  to  make  a  diag- 
nosis, and  I  need  not  dwell  longer  on  this  point  than  to 
refer  to  the  difficulty  of  differentiating  this  disease  from 
chronic  articular  ostitis  of  the  hip,  or  synovitis,  if  the  bursa 
under  the  ilio-psoas  be  the  one  implicated.  The  freedom  of 
all  the  joint  movements,  save  flexion  in  extremes,  and  the 
presence  of  the  inguinal  tumor,  which  increases  and  sub- 
sides under  exercise  and  rest  respectively,  are  the  points  on 
which  a  differential  diagnosis  can  be  made.  This  is  more 
fully  illustrated  in  a  case  which  is  reported  on  page  115. 

The  TREATMENT  will  depend,  in  a  measure,  on  the  locality 
of  the  bursa  inflamed,  and  upon  the  severity  of  the  symp- 
toms. Blistering  over  the  gluteal  bursae  seems  to  have 
given  me  good  result  in  a  single  case,  and  this  still  is  a  very 
popular  method.  In  one  case  it  did  no  good  whatever,  and 
the  tumor  yielded  to  a  compress  and  the  roller. 

The  removal  of  the  contents  by  the  hypodermic  syringe 
and  the  injection  of  iodine  into  the  sac  has  been  employed 
with  fair  result  in  bursae  in  other  parts  of  the  body, -and  I 
should  certainly  employ  this  method  in  another  case. 

The  rupture  of  the  sac  by  percussion  or  direct  blow, 
when  the  tumor  lies  over  a  bony  surface,  as  in  the  one  over 
the  trochanter,  would  commend  itself,  but  for  the  danger.of 
excif.ing  inflammation  in  parts  contiguous. 

Then  this  might  be  brought  about  by  valvular  puncture 
or  incision.  The  fluid  would  escape  into  the  soft  parts  and 
be  absorbed.  A  compress  worn  subsequent  to  this  pro- 
cedure over  the  parts  will  prevent  the  reaccumulation,  un- 
less this  be  one  of  those  irritated  bursae,  such  as  the  one  in 
my  first  case  proved  to  be. 

I  have  no  experience  in  the  wearing  of  setons  in  bursae 
of  any  kind,  and  on  general  principles  I  should  hesitate 
long  before  recommending  this  treatment  in  inflamed  bur- 
sae about  the  hip.  A  suppuration  is  induced,  and  the  drain- 
age being  poor,  the  neighboring  parts  are  almost  sure  to 
participate.  Even  this  treatment  for  the  prepatellary 


BURSITIS  OF  THE  HIP.  115 

bursae  is  not  looked  upon  with  favor  by  many  good  sur- 
geons. 

In  those  sacs  which  show  such  a  tendency  to  refill,  I 
should  prefer  excision.  Corresponding  last  year  with  Mr. 
Mitchell  Banks  of  the  Liverpool  Royal  Infirmary,  that 
gentleman  very  kindly  sent  me  an  extract  from  the  Liver- 
pool Medico-Chirurgical  Journal  entitled,  "  Notes  on  the 
Surgery  of  Bursae,"  published  January,  1882,  and  in  these 
notes  I  find  two  cases  which  he  reports  as  at  present  in 
his  wards.  The  disease  was  confined  to  the  bursa  over  the 
most  prominent  part  of  the  great  trochanter.  I  take  plea- 
sure in  reproducing  them  in  this  connection. 

"The  first  patient,  Lydia  T.,  aged  20,  told  us  that  some 
four  years  ago  she  was  sliding  in  the  street,  when  she  fell 
and  struck  her  left  hip  against  the  wheel  of  a  passing  wag- 
gon. A  lump  followed,  which  burst  in  about  a  week. 
There  remained  a  small  sinus,  which  has  continued  to  dis- 
charge slightly  ever  since,  and  in  the  neighborhood  of 
which  she  has  suffered  pain  at  intervals.  Some  three  weeks 
before  admission  the  parts  arounds  the  sinus  became  much 
swollen  and  very  hard,  so  that  her  pain  induced  her  to 
come  to  hospital.  The  only  point  was  whether  there  was 
any  disease  either  of  the  joint  or  of  the  femur.  All  the 
ordinary  tests  indicated  that  the  joint  was  quite  sound, 
while  the  most  careful  probing  failed  to  reach  bone. 
Clearly  the  treatment  was  simple  enough  then,  namely,  to 
lay  the  sinus  open  to  its  uttermost  end.  Ether  being 
given,  this  was  done,  and  then  a  smooth  cavity  lined  with 
granulations  was  reached,  which  was  pretty  evidently  the 
sac  of  the  trochanteric  bursa  reduced  to  the  condition  of  a 
very  chronic  abscess  cavity.  A  free  crucial  opening  into 
this  was  made,  and  it  was  tightly  packed  with  lint  dipped 
in  carbolized  oil.  It  is  now  growing  up  to  the  surface,  and 
in  two  or  three  weeks  will  be  quite  healed  over.  Although 
I  was  pretty  confident  that  the  cavity  reached  here  was  the 
sac  of  an  old  inflamed  bursa,  I  could  not  be  absolutely  cer- 
tain, as  it  was  the  first  case  I  had  seen.  But  the  diagnosis 
was  confirmed  by  the  appearances  presented  by  the  case  of 
Mary  H.,  aged  24,  who  was  admitted  about  a  fortnight 
after  the  previous  case. 

Two  years  ago  she  fell  down  stairs,  after  which  she  had 
pain  over  the  outer  and  upper  part  of  the  right  thigh, 
which  was  followed  in  the  course  of  a  week  by  a  lump 
about  the  size  of  a  hen's  egg,  when  first  she  noticed  it.  It 


Il6  DISEASES  OF  THE  HIP. 

has  remained  pretty  stationary  ever  since;  sometimes,  she 
thinks,  increasing  a  little  in  size,  and  sometimes  diminish- 
ing. She  had  no  distinct  pain  in  it,  but  it  made  the 
whole  leg  ache  and  feel  so  weak  that  she  determined  to 
have  it  removed.  Over  the  trochanter  was  found  a 
smooth,  globular,  somewhat  elastic  tumor,  quite  free,  and 
moving  readily  about.  The  skin  over  it  was  unaffected, 
and  there  was  no  pain  on  handling.  Two  of  my  col- 
leagues examining  it  without  knowing  the  history,  pro- 
nounced it  a  fatty  tumor.  At  my  first  examination  I  did 
also;  but  a  day  or  two  after  patient's  admission  her  history 
was  carefully  taken,  and  the  tumor  again  examined  before 
operation,  chiefly  as  a  part  of  the  ordinary  clinical  training 
of  the  students;  and  not  for  my  own  satisfaction.  At  this 
examination,  however,  the  history  attracted  my  attention, 
and  a  more  careful  handling  convinced  me  that  the  tumor 
was  fluid  and  not  solid.  So  a  fine  trochar  was  brought 
and  thrust  into  it,  and  through  it  came  some  dark-colored 
serum.  We  thereupon  all  rejoiced  at  having  discovered  a 
second  trochanteric  bursa,  and  the  subsequent  small  opera- 
tion was  watched  with  considerable  interest.  Under  ether 
I  made  a  free  incision  through  skin  and  fat  into  the  tumor. 
Some  serum  escaped,  and  then  a  considerable  quantity  of 
stuff  which  looked  like  semi-liquefied  fat,  but  which  turned 
out  to  be  lymph  floating  in  the  serum.  From  being  worked 
up  and  down  in  the  sac,  this  lymph  was  evidently  acquir- 
ing a  definite  form,  and  it  was  pretty  clear  that  after  a  while 
it  would  have  broken  up  into  a  mass  of  small  bodies,  which 
would  in  time  have  acquired  the  peculiar  melon-seed  shape, 
with  which  one  is  familiar  in  diseased  synovial  bursae  con- 
nected with  tendons.  My  first  idea  was  simply  to  plug  the 
sac,  and  cause  it  either  to  slough  out,  or  granulate  up;  but 
it  seemed  so  tough  and  shining,  that  I  was  tempted  to  dis- 
sect it  out,  and  very  easily  so,  the  only  surface  to  which  it 
was  intimately  adherent  being  the  fascia  and  periosteum 
over  the  trochanter.  Thus  the  wound  was  reduced  to  a 
very  simple  matter,  and  it  will  probably  heal  before  that  of 
the  first  mentioned  case." 

The  cases  Mr.  Banks  first  reports  are  interesting  from  a 
therapeutical  point.  The  method  of  operating  employed 
by  this  surgeon  is  to  make  two  incisions,  and  speaking  of 
the  objections  to  excising  bursae,  he  makes  the  following 
remark: 

"  In  performing  an  operation  which  is  not  necessary  for 


I 

BURSITIS  OF  THE  HIP.  117 

the  saving  of  life  (an  operation  of  complaisance,  as  the. 
old  surgeons  would  have  termed  it),  one  has  to  balance 
against  the  annoyance  produced  by  the  complaint,  the  pain 
of  the  operation  at  the  moment  of  doing  it,  and  the  subse- 
quent risk  caused  by  it.  With  regard  to  pain,  that  is  a 
thing  of  the  past,  as  far  as  the  work  of  the  knife  is  con- 
cerned. As  for  the  subsequent  risk,  antiseptics  have  put 
such  an  operation  as  removal  of  the  bursa  patellae  almost 
on  a  level  with  the  commoner  surgical  proceedings  of 
paring  one's  corns  and  cutting  one's  nails — operations,  by 
the  way,  which  have  both  been  followed  by  fatal  results, 
but  which,  in  spite  of  that,  are  universally  practised." 

PROGNOSIS. — If  one  can  recognize  a  bursa  about  the  hip 
under  a  primary  inflammatory  attack,  the  prognosis  ought  to 
be  extremely  favorable,  not  only  for  speedy  recovery  but  per- 
fect result.  If  not  recognized,  however,  until  the  sac  has  be- 
come irritable  and  thickened,  then  one  cannot  predict  the 
time  when  a  spontaneous  cure  will  follow.  When  the  ilio- 
psoas  bursa  is  affected,  the  prognosis  should  be  given  with 
extreme  caution.  I  am  pretty  well  convinced  that  grave 
diseases  of  the  hip-joint  arise  out  of  just  such  conditions. 

Take  the  following,  which  has  been  to  me  a  most  interest- 
ing case,  not  only  of  bursitis,  but  of  subsequent  joint  dis- 
eases: 

I  saw  for  the  first  time,  in  the  latter  part  of  April,  1880, 
a  plump,  fairly  nourished  girl,  aged  eight  years,  and  while 
there  was  a  tuberculous  element  in  the  father's  family,  the 
child  herself  had  been  in  good  health  all  her  life.  It  was 
reported  that  two  years  before  this  date  she  had  been  run 
over  by  a  wagon  and  severely  bruised.  The  effects  soon 
passed  off,  it  was  believed,  and  nothing  further  was  ob- 
served until  she  began  to  complain  of  pain  just  above  the 
right  knee,  in  February,  1880.  She  continued  at  school, 
though,  and  the  pain  was  felt  chiefly  by  night,  when  the 
parents  would  hear  cries  during  her  sleep.  No  other 
symptoms  were  discovered  until  I  found  a  fulness  in  the 
right  groin,  below  Poupart's  ligament.  This  fulness  did 
not  extend  into  the  iliac-fossa,  and  I  could  not  find  any  re- 
sistance to  the  normal  movements  of  the  joint.  There 
was  a  slight  limp,  right  side,  but  it  was  not  the  "hip 
limp."  The  natis  on  this  side  was  broadened  a  little,  and 
the  gluteo-femoral  crease  was  lowered  and  shortened.  The 
diagnosis  lay  between  a  glandular  periarthritis,  and  an 
articular  ostitis.  Under  expectant  treatment  the  lameness 


Il8  DISEASES  OF  THE  HIP. 

soon  grew  less  marked — scarcely  appreciable — but  the  in- 
guinal fulness  remained  about  in  stain  quo  ante.  The  lame- 
ness disappearing,  a  discharge  was  granted  for  the  22nd  of 
June.  There  was,  however,  on  this,  the  day  of  her  discharge, 
a  slight  yet  appreciable  resistance  to  flexion  of  the  thigh 
beyond  90°.  There  was  no  atrophy,  and  no  joint  tender- 
ness. 

Believing  this  tumor  to  be  glandular,  I  employed  iodine 
internally  and  externally,  and  occasionally  applied  a  blister 
over  the  parts.  In  August,  lameness  was  induced  by  going 
up  stairs,  and  this  slight  exercise  indicated  pretty  well 
the  locality  of  the  disease.  In  November  she  became  lame 
again,  though  prior  to  this  she  had  been  very  active.  The 
inguinal  tenderness  was  very  marked,  and  this  tumefaction, 
or,  tumor,  still  existed. 

In  January,  1881,  I  was  quite  positive  in  finding  an  elastic 
or  cystic  element  in  this  tumor,  and  I  made  a  diagnosis  of 
bursitis  just  beneath  the  ilio-psoas,  and  in  almost  direct 
contact  with  the  synovial  membrane.  The  tumor  was  not 
painful  on  handling,  and  was  the  size  of  a  pullet's  egg. 
There  was  no  lameness  whatever,  unless  a  transient  lame- 
ness after  rising  from  bed  in  the  morning.  In  March,  I  was 
more  confident  of  my  diagnosis,  and  urged  the  use  of  the 
hypodermic  as  a  means  of  diagnosis  at  least,  but  I  could  not 
get  the  consent  of  the  surgeon  in  charge  of  the  case.  Other 
remedies  were  employed,  liniment,  for  instance.  She  be- 
came better,  and  worse  again  throughout  the  summer,  but 
always  retained  that  fulness  in  the  groin  more  or  less 
prominent. 

Some  days  it  would  be  quite  large,  and  her  symptoms 
w.ould  be  aggravated.  Then,  again,  it  would  be  small,  and 
scarcely  any  lameness  could  be  detected,  and  the  only  sign 
present  was  resistance  to  complete  flexion. 

In  October,  1881,  there  appeared  for  the  first  time  real 
symptoms  of  joint  disease.  The  hip  was  nearly  locked, 
and  there  was  much  joint  tenderness.  She  was  re-admitted, 
and  under  expectant  treatment  grew  worse,  so  that  by 
February  she  had  passed,  with  a  great  deal  of  suffering,  too, 
through  the  first  stage  of  joint  disease,  into  the  second, 
with  impending  abscess  and  great  deformity.  The  father 
removed  her  at  this  time,  and  placed  her  under  the  care  of 
another  surgeon.  He  made  out  scrofulous  ostitis  of  the 
hip,  implicating  the  acetabular  parts,  and  has  her  now 


,'BURSITIS  OF  THE  HIP.  119 

under  treatment.     An  abscess  formed,  and  was  aspirated. 

Dr.  T.  M.  Taylor,  of  our  staff,  very  kindly  traced  the  case 
out  in  June,  and  found  the  girl  in  a  Thomas'  splint,  limb 
straight  and  in  good  position.  The  girl  had  no  pain,  and 
was  in  a  fair  condition  of  health.  The  hip  was  fixed  by  the 
splint,  which  was  not  removed  ;  the  limb  was  atrophied 
nearly  two  inches  in  circumference,  but  seemed  equal  in 
length. 

Such  cases  as  the  one  just  recorded  furnish  texts  for 
extended  comment.  Here  was  this  tumor  duly  recognized 
long  before  any  inflammatory  mischief  had  been  done  the 
joint,  and  here  was  the  knowledge  of  the  disastrous  effects 
of  disease  at  this  articulation.  It  would  have  been  better 
to  have  removed  the  offending  bursa,  taking  all  the  risks 
of  so  delicate  an  operation.  In  this  day  of  antiseptic  sur- 
gery, with  such  facilities  for  diminishing  the  danger  of 
inflammatory  processes,  little  fear  need  be  entertained  in 
making  an  operation  wound,  however  large  and  however 
extensive,  provided  it  is  demanded  by  the  exigencies  of 
the  case.  In  an  acute  bursitis  rational  therapeautics  de- 
mand rest  and  expectant  measures  ;  but  if  the  lesion  gets  to 
be  a  chronic  and  a  recurring  one,  then  excision  of  the 
tumor,  or  obliteration  of  it  by  surgical  means  is  the  only 
rational  treatment  to  be  considered. 

To  recapitulate  : 

1.  The  bursae  about  the  hip  are  occasionally  inflamed  as 
a  direct  result  of  strain,  contusion,  or  exposure  to  cold. 

2.  Ordinarily  they  excite  a  very  trifling  amount  of  in- 
flammation in  adjacent  tissues  ;  occasionally,  however,  the 
joint  is  implicated,  especially  if  the  bursa  beneath  the  ilio- 
psoas  be  the  one  diseased. 

3.  In  a  certain  number  of  cases  of  acute  bursitis  the  ten- 
dency to  recurrence  is  very  great,  and  this  is  chiefly  true 
of  those  wherein  a  diagnosis  has  not  been  made  until  two 
or  more  attacks  have  already  appeared. 

4.  The  diagnosis  depends  on  the  history,  the  knowledge 
of  the  anatomical  locality  of  the  normal  bursae,  the  pres- 
ence of  a  cystic  tumor,  and   the  exploration  of  the  same 
and    the    exclusion    of    synovial,   periarticular  and   bone 

..diseases. 

5.  The  treatment  in  the  first  attack  should  be  blistering, 
if  the  process  be  not  acute  ;  hot  fomentations  if  acute,  rest 
and  compress.     If  recurrences  have  already  taken  place, 


120  DISEASES   OF   THE   HIP. 

and  the  sac  be  an  irritable  or  a  sero- purulent  one,  the  de- 
struction or  the  removal  of  the  same  is  the  only  treatment 
that  holds  out  any  prospect  of  a  cure. 

6.  It  is  dangerous  to  permit,  for  a  long  time,  inflamma- 
tion of  a  bursa  which  communicates  with  the  joint,  or 
which  lies  directly  upon  the  capsular  ligament. 


CHAPTER -VIII. 

ACUTE  PRIMARY  SYNOVITIS. 

The  serous  membrane  which  lines  the  capsule  and  is 
spread  over  a  large  surface  of  the  articulation  occasionally 
becomes  the  seat  of  a  primary  inflammation,  marked  by  acute 
symptoms  and  running  a  comparatively  brief  course.  The 
age  at  which  children  are  thus  affected  is  from  eight  to 
fifteen  years.  The  invasion  is  acute  and  well-defined.  The 
mother  will  be  able  to  name  the  day,  the  hour  frequently, 
when  the  first  pain  was  experienced,  and  this  is  generally 
preceded  a  day  or  two  by  a  little  lameness,  sometimes 
merely  a  sense  of  fatigue.  The  joint  soon  becomes  ex- 
ceedingly tender,  and  the  patient  will  be  unable  to  walk 
during  the  first  and  second  weeks.  In  chronic  ostitis 
of  the  hip  the  inability  to  walk  does  not,  as  a  rule, 
come  until  several  months  after  the  invasion.  Lameness, 
it  must  be  remembered,  is  the  first  sign,  but  this  is  very 
slight,  and  it  is  a  long  time  before  the  patient  is  actually 
unable  to  walk.  Pain  in  the  branches  of  the  obturator — 
at  the  knee,  for  instance — will  follow  crowding  of  the  artic- 
ular surfaces  together.  The  intensity  of  the  pain  will,  of 
course,  be  in  proportion  to  the  acuteness  of  the  inflamma- 
tory process. 

The  case  of  a  boy,  aged  twelve  years,  who  came  into  the 
hospital  in  October,  1879,  furnishes  a  good  clinical  history 
of  this  disease.  He  came  from  a  country  town,  and  was  a 
muscular-looking  lad.  There  was  a  history  of  phthisis  in 
both  branches  of  the  family,  and  the  father  was  reported  to 
be  suffering  at  the  time  from  sciatica.  With  the  exception 
of  a  slight  attack  of  what  was  regarded  as  malarial  fever 
two  years  since,  the  boy  himself  had  been  in  excellent 
health  until  one  month  before  the  date  of  admission,  when 
he  was  seized  with  pain  on  the  inner  side  of  the  right  thigh 
He  had  been  in  bathing  quite  frequently  during  the  latter, 
part  of  the  summer — three  or  four  times  a  day — and  it  was 
to  exposure  or  fatigue  that  his  pain  was  attributed.  He 


122  DISEASES  OF  THE  HIP. 

was  able  to  walk  the  first  day,  although  he  was  decidedly 
lame.  On  the  third  day  he  took  to  bed,  so  tender  had  the 
parts  in  and  about  the  hip  become.  There  was  consider- 
able febrile  disturbance,  without  constipation,  and  morphia 
had  to  be  administered  every  night  to  allay  the  pain.  The 
hip  and  the  knee  alternately  had  been  the  seat  of  pain,  and 
the  limb  could  with  difficulty  be  moved  at  all.  Recently  he 
had  suffered  most  in  the  distribution  of  that  branch  of  the 
obturator  which  supplies  the  knee.  He  held  the  thigh 
acutely  flexed  while  lying  in  bed. 

He  was  taken  from  his  bed  this  morning  and  brought 
into  the  hospital.  Is  able  to  stand,  although  the  weight 
is  borne  on  the  left  limb,  while  the  right  is  a  little  ad- 
vanced, the  foot  being  everted.  He  remarks  that  this 
is  the  first  time  he  has  been  able  to  set  his  foot  squarely 
upon  the  floor  since  the  beginning  of  his  illness.  As  he 
attempts  to  turn,  he  does  so  by  means  of  the  left  foot.  Can 
walk  only  when  well  supported  on  each  side.  He  is  well- 
developed,  but  has  a  face  that  is  indicative  of  great  suffer- 
ing. It  is  a  painful  expression  he  has.  The  thorax  and  the 
spinal  column  are  examined,  with  negative  results.  There 
is  much  width  to  the  nates  on  the  right  side,  the  fold  is 
obliterated  ;  no  tenderness  over  the  sacro-iliac  junction, 
and  none  elicited  on  crowding  the  alae  of  the  pelvis  together. 
No  infiltration  in  the  groin  or  in  the  gluteal  region,  no  ten- 
derness here  on  handling  the  parts.  The  superficial  ingui- 
nal glands  are  a  little  enlarged.  Light  pressure  in  the 
groin  or  over  the  trochanter  gives  rise  to  no  pain  ;  no  pain 
on  pressure  along  the  shaft  of  the  femur.  If  firm  pressure 
be  made  over  the  trochanter  in  the  line  of  the  neck  of  the 
bone,  he  winces  very  decidedly,  and  refers  the  pain  to  the 
outer  aspect  of  the  thigh  and  about  the  knee.  Concussion 
of  the  joint  gives  rise  to  much  pain. 

No  dulness  or  tenderness  in  either  the  iliac  fossa  or  the 
ilio-costal  space.  The  limbs  are  equal  in  size,  except  in 
their  upper  thirds,  where  the  right  one  is  one  inch  larger 
than  the  left.  This  may  be  the  result  of  two  fly-blisters  on 
the  inner  side  of  the  thigh,  cicatrices  of  which  now  remain. 
They  were  applied  by  order  of  the  physician  at  his  home. 

He  cannot  be  induced  to  flex  the  thigh  beyond  135°,  nor 
\vill  he  permit  extension  beyond  160°.  Abduction,  adduc- 
tion and  rotation  are  quite  impossible,  so  marked  is  the 
reflex  muscular  action  when  these  movements  are  at- 
tempted. The  rectal  temperature  is  102-5°, 


ACUTE  PRIMARY  SYNOVITIS.  12$ 

A  counter-irritant  is  applied  this  evening  over  the  troch- 
anteric  region. 

Two  days  after  admission,  he  is  walking  without  sup- 
port, and  the  improvement  is  at  least  fifty  per  cent.  The 
blistered  surface  is  being  poulticed  every  six  hours,  al- 
though it  has  healed,  and  the  contour  of  the  nates  is  nearly 
restored. .  He  walks  with  much  facility,  limping  very  little. 
No  joint  tenderness  can  be  elicited.  It  is  thought  neces- 
sary, however,  to  repeat  the  vesication,  and  another  plaster 
is  applied  this  evening  in  the  same  region. 

This  last  vesicated  surface  was  a  long  time  healing,  and 
there  remained  early  in  November  many  superficial  ulcers 
in  its  neighborhood.  During  the  last  week  in  October  he 
walked  with  a  mere  trace  of  a  limp,  and  he  had  no  pain 
until  one  night,  when  by  accident  another  patient  ran 
against  him  the  wheel  of  a  rolling  chair,  striking  the  gluteal 
region  with  considerable  force.  Consequently  he  was  very 
lame  next  morning,  and  the  soft  parts,  the  inguinal  glands 
especially,  were  extensively  infiltrated.  No  joint  tender- 
ness could  be  found,  however,  by  the  different  tests,  and 
the  pain  and  tenderness  were  thus  proven  to  be  periartic- 
ular.  It  would  seem,  then,  that  the  contusion  had  simply 
aggravated  the  periarthritic  infiltration  resulting  from  the 
second  vesication,  without  injuring  the  joint.  He  went  to 
bed  for  a  few  days,  and  the  poultices  were  renewed. 

The  ulcers  were  most  obstinate,  and  the  periarthritis  of 
our  own  making  after  his  admission  to  the  hospital  gave 
him  much  more  trouble  than  did  the  synovitis.  They  (the 
ulcers)  were  finally  scabbed  over,  and  at  the  close  of  the 
first  week  in  October  the  boy  was  submitted  to  a  thorough 
examination  regarding  his  joint  functions,  which  were  found 
to  have  been  perfectly  restored. 

Discharged,  January  12, 1880.  There  were  no  signs  of  any 
disease,  nor  any  remnants  of  disease,  with  the  exception  of 
the  roughened  skin  af  the  sites  of  blisters.  His  general 
health  was  excellent. 

October  3ist,  the  father  writes  me,  in  response  to  a 
letter  of  inquiry,  that  there  has  been  no  sign  of  any 
relapse,  and  that  the  boy  is  still  free  from  pain  and  lame- 
ness. Late  inquiries  have  been  answered  in  the  same  way. 
It  will  be  seen  that  febrile  disturbance  was  a  marked  fea- 
ture in  the  early  stage. 

Effusion  into  the  capsule  can  generally  be  recognized 
when  other  symptoms  are  present  which  go  to  confirm 


124  DISEASES  OF  THE  HIP. 

its  existence.  A  degree  of  tension,  with  increase  in  size  of 
the  nates,  can  be  easily  recognized.  A  boy  aged  eleven 
was  admitted  in  August,  1876.  A  week  before  his  admis- 
sion, without  any  known  provocation,  he  suddenly  com- 
plained of  weakness,  tenderness  and  pain,  which  symptoms 
have  increased  in  severity.  He  stood  on  examination  with 
left  thigh  advanced  semi-flexed  and  everted,  and  walked 
with  a  decided  limp.  The  left  natis  was  broad,  quite  tense, 
and  there  was  marked  tenderness  on  pressure  over  the  tro- 
chanter.  The  superficial  inguinal  ganglia  were  enlarged. 
The  thigh  could  be  extended  to  an  angle  of  165°  without 
tilting  the  pelvis.  There  was  limited  motion  at  the  joint, 
but  any  attempt  to  flex  was  opposed  by  muscular  resist- 
ance, ad- and  abduction  being  likewise  opposed.  No  short- 
ening, and  no  atrophy.  Pain  was  complained  of  when  the 
articular  surfaces  were  approximated.  A  diagnosis  of 
synovitis  was  made,  and  on  the  day  following  he  was  sub- 
mitted to  a  more  thorough  examination.  The  surface-tem- 
perature on  left  side  over  the  joint  was  two  degrees  lower 
than  that  at  same  point  on  right  side.  Measurement  around 
groin  and  over  trochanter  for  the  right  side  was  fifteen  and 
a  half  inches,  while  on  the  left  side  it  was  seventeen  and  a 
half ;  from  coccyx  to  anterior  superior  spinous  process, 
right  side  eight  inches,  left  side  nine.  The  usual  local 
treatment  was  begun  without  delay. 

The  blistered  surface  was  poulticed  with  flaxseed  meal 
on  the  following  morning,  and  renewed  every  six  hours  for 
three  days,  then  dressed  with  simple  dressings  until  healed. 
There  was,  ten  days  after  admission,  one  and  a  half  inches 
difference  in  the  size  of  the  nates,  as  measured  around  groin 
and  over  trochanter. 

The  decrease  of  the  swelling  continued  ;  the  boy  was  free 
from  pain,  and  the  limb  was  almost  straight  at  the  end  of 
ten  days  more. 

Near  the  close  of  the  month  there -was  only  a  very  slight 
limp.  No  resistance  to  flexion,  extension,  ab-  or  adduction. 
There  was  no  difference  in  size  or  in  length  of  limbs.  The 
measurements  over  trochanter  and  around  groin  on  both 
sides  were  identical ;  those  from  coccyx  to  anterior  superior 
spine,  on  both  sides,  likewise  identical.  The  surface-tem- 
perature over  the  right  hip-joint  is  one  half  degree  higher 
than  that  over  left.  There  is  still  a  shade  of  flattening. 

The  contour  of  the  nates  was  to  all  appearances  re- 
stored by  the  ist  of  October.  There  was  no  pain,  no  ten- 


ACUTE  PRIMARY  SYNOVITIS.  125 

/ 

erness,  no  limp,  and  he  was  discharged  cured  a  few  days 
later. 

I  saw  the  boy  after  a  lapse  of  four  years,  and  no  relapse 
had  ever  occurred. 

There  are  many  good  observers,  I  am  well  aware,  who 
teach  and  firmly  believe  that  most  of  the  cases  called  "hip- 
disease"  begin  as  a  synovial  inflammation  ;  and  I  am  quite 
sure  that  this  impression  is  often  produced  by  a  failure  on 
their  part  to  properly  consider  the  prodromal  signs,  if  I 
may  so  call  them,  that  precede  the  first  exacerbation  which 
induced  the  parents  or  the  friends  to  seek  advice.  Unless 
the  surgeon  closely  cross-examines  the  patient  he  will  be 
led  to  regard  this  exacerbation  as  the  beginning  of  the  dis- 
ease. The  parents  insist  on  it  and  then  they  will  say,  after 
a  while,  apologetically,  it  would  seem,  "  Yes,  he  did  walk  a 
little  lame;  but  then  the  lameness  was  of  no  account."  I 
have  had  cases  come  under  observation  a  second  time,  after 
a  lapse  of  many  months,  and  the  history  of  a  recent  invasion 
would  be  given,  when  I  would  remember  the  name,  look 
over  my  records,  and  find  the  same  case  noted  with  similar 
signs.  These  had  subsided  to  a  great  degree,  and  in  the 
interval  only  an  occasional  limp  after  exercise  would  be  ap- 
parent. Cases  exactly  like  these  I  have  had  under  observa- 
tion in  the  hospital,  and  the  only  signs  I  could  detect,  on 
repeated  examinations  at  long  intervals,  would  be  a  slight, 
yet  appreciable  amount  of  resistance  to  flexion  when  carried 
beyond  eighty  degrees,  and  to  rotation  or  to  abduction.  A 
limp  was  not  always  recognized.  , 

The  point,  then,  I  endeavor  to  make  is  this:  that  an  acute 
primary  synovitis  has  a  distinct  period  of  invasion,  and  fur- 
nishes a  clear  and  well-defined  clinical  history. 

The  following  case  referred  to  me  for  hospital  treatment 
by  Dr.  Wm.  T.  Bull,  on  September  19,  1879,  illustrates  a 
not  very  severe  type  of  the  disease.  It  was  that  of  a  girl, 
aged  nine. 

With  the  exception  of  intemperance  in  the  father,  the 
family  history  on  both  sides  of  the  house  was  good;  the 
hygienic  surroundings  had  been  poor,  yet  the  child  had 
been  in  good  health  up  to  the  invasion  of  the  present  dis- 
ease, the  first  symptoms  of  which  appeared  on  the  morn- 
ing of  the  i ath,  without  any  assignable  cause,  unless  per- 
haps exposure  to  cold  may  be  regarded  as  a  cause.  The 
girl  walked  a  little  lame  that  morning,  favoring  the  left 
side,  and  referring  the  pain  to  the  knee;  was  not  very  lame, 


126  DISEASES  OF  THE  HIP. 

and,  indeed,  rested  very  well  that  night;  but  the  next  morn- 
ing, the  isth,  she  was  unable  to  walk  at  all,  so  tender  the 
joint,  and  so  acute  the  pain.  In  the  afternoon  fever  came 
on  and  persisted  througout  the  entire  night.  She  suffered 
very  much  every  day  and  every  night  until  the  day  of  her 
admission.  While  asleep,  the  limb  was  flexed  at  the  hip 
and  at  the  knee.  The  pain  had  been  paroxysmal,  and  had 
been  referred  always  to  the  groin,  the  inner  side  of  the  thigh, 
and  the  knee.  The  appetite  had  been  good  and  the  bowels 
regular.  The  child  was  carried  in  with  the  greatest  care, 
and  considerable  difficulty  was  experienced  in  preparing 
her  for  examination. 

While  the  patient  was  quite  anaemic,  the  muscular  system 
was  fairly  developed.  As  she  stood,  the  right  limb  bore  the 
weight,  while  the  left  was  slightly  flexed  at  the  knee,  the 
foot  being  everted.  She  was  able  to  walk  a  short  distance 
in  the  room,  yet  the  lameness  was  very  marked.  On  ex- 
amination, the  heart  and  lungs  were  found  to  be  normal. 
Firm  pressure  over  the  trochanter,  in  the  line  of  the  axis  of 
the  neck  of  the  bone,  caused  acute  pain,  which  was  referred 
to  the  inner  side  of  the  thigh  and  knee.  Percussion  of  the 
flexed  knee,  in  the  axis  of  the  femur,  did  not  produce  pain. 
There  was  no  tenderness  on  firm  pressure  in  the  groin  or 
in  the  iliac  region  or  in  the  ilio-costal  space.  There  was  no 
infiltration  or  swelling  in  any  of  the  localities  just  enumer- 
ated. The  nates  on  the  left  side  was  broadened,  though 
there  was  no  infiltration  here.  The  superficial  inguinal 
glands  were  slightly  enlarged  on  both  sides.  The  thigh 
could  not  be  extended  beyond  150°  without  tilting  the  pel- 
vis; it  could  be  flexed  to  90°,  though  she  complained  of 
pain  in  the  groin  when  it  was  forced  beyond  this  point. 
Abduction  and  adduction  could  be  made  over  one  half  the 
normal  arcs.  Pulse  160;  rectal  temperature  101.5°.  A 
blister  was  applied  over  the  gluteal  region  the  night  of  her 
admission,  and  cod-liver  oil  and  iron  mixtures  were  ordered 
as  routine. 

September  28th.— Most  decided  relief  since  admission.  She 
is  now  free  from  pain,  and  walks  quite  easily,  only  a  slight 
halt  being  perceptible.  No  tenderness  in  or  about  the  joint. 
Another  blister  was  applied  on  the  evening  of  the  3oth,  and 
on  October  iyth  it  was  recorded  that  she  had  grown  com- 
paratively stout,  and  walked  without  an  appreciable  limp. 
The  only  change  observed  in  the  natis  was,  that  the  supra- 
trochanteric  dimple  was  a  little  shallower  than  that  on  the 


ACUTE  PRIMARY  SYNOVITIS. 

right  side.  The  limbs  were  equal  in  size,  and  movements 
at  the  joint  were  perfect  and  painless.  Pressure  over  the 
trochanter,  in  the  direction  of  the  joint,  gave  no  pain;  con- 
cussion gave  none.  The  cure  was  complete. 

October  24th. — Submitted  to  a  thorough  examination,  and 
the  supra-trochanteric  dimple  found  normal.  No  sign  or 
symptom  of  disease.  Discharged  this  date,  the  parents 
promising  to  report  on  the  first  sign  of  any  relapse. 

The  case  of  a  girl,  aged  six  years,  who  entered  the  hospi- 
tal February  19,  1874,  differs  materially  from  the  one  just 
narrated,  and  yet  the  difference  is  in  the  acuteness  and  the 
severity  of  the  symptoms.  In  this  the  invasion  was  almost 
instantaneous.  When  she  was  brought  into  the  office  the 
pain  was  so  intense  that  an  examination  was  impracticable, 
in  fact  it  was  deferred  until  she  could  be  transferred  to  the 
ward. 

The  family  was  found  healthy  and  free  from  disease;  the 
girl  herself  was  an  only  child,  and  had  always  been  in  ex- 
cellent health.  She  was  considered  perfect  in  health  and 
limb  on  the  evening  of  the  i6th — three  days  before — went  to 
bed  in  that  condition,  and  was  awakened  suddenly  during 
the  night  by  acute  pain  referred  to  the  right  hip-joint.  Her 
screams  alarmed  the  household.  Febrile  movement  was 
great,  and  in  the  morning  the  child  was  quite  unable  to 
stand  on  the  limb.  The  pain  and  tenderness  seemed  to  in- 
crease, and  the  loss  of  strength  from  sleeplessness  and  gen- 
eral constitutional  disturbance  soon  became  alarming. 

On  examination  this  evening  the  tongue  is  coated,  the 
patient  cannot  be  induced  to  stand  alone,  much  less  to  take 
a  step,  and  after  much  persuasion  she  allows  herself  to  be 
held  in  the  standing  posture,  when  the  right  lower  extrem- 
ity is  suddenly  adducted,  advanced,  and  semi-flexed;  little 
or  no  change  has  taken  place  in  the  nates,  there  is  no  atro- 
phy of  the  limb,  and  no  shortening.  Any  attempt  at  active 
or  passive  motion  causes  intense  pain  at  the  hip,  though  by 
grasping  the  thigh  carefully  and  firmly,  making  traction 
the  while,  the  muscles  hitherto  in  tonic  rigidity  gradually 
relax,  and  a  great  sense  of  relief  is  experienced.  Acute 
synovitis  of  the  hip  is  diagnosticated,  and  a  fly  blister  ap- 
plied to-night. 

March  ist. — Almost  entirely  free  from  pain,  and  condi- 
tion is  much  improved. 

March  2  ist. — A  second  blister  applied  on  recurrence  of  pain. 
From  this  time  forward  the  case  progressed  as  favorably  as 


128  DISEASES  OF  THE  HIP. 

f        f 

could  have  been  desired,  and  in  October  it  is  reported  that 
little  or  no  deformity  exists;  the  child  walks  with  great 
facility.  An  examination  is  made  August  4,  1875,  no  un- 
favorable symptom  having  occurred  in  the  mean  time,  and 
the  result  is  as  follows:  general  health  robust;  stands  with 
right  limb  slightly  advanced,  walks  and  runs  freely,  though 
favoring  this  side;  contour  of  hip  almost  perfectly  restored; 
flexion,  extension,  ab-  and  adduction  easily  accomplished; 
no  pain  or  tenderness,  no  shortening  or  atrophy;  with  the 
exception  of  a  mere  limp  the  cure  is  perfect.  This  lameness 
must  be  due  to  some  loss  of  substance  in  the  joint  struc- 
tures— a  theory  very  plausible  in  view  of  the  severity  of  the 
primary  lesion.  The  girl  was  seen  by  me  a  year  or  so  later, 
and  this  limp  could  scarcely  be  detected. 

This  case  began  as  some  bone  diseases  do  begin,  viz.,  as  ' 
an  acute  synovitis.     The  acuteness  of  the  inflammation  in- 
duced by  contiguity  a  like  lesion  (though  modified)  in  the 
bony  tissues. 

It  is  needless  to  cite  further  instances.  I  have  cited  the 
above  because  it  is  difficult  to  formulate  symptoms — symp- 
toms, I  mean,  that  are  pathognomonic.  One  must  examine 
the  case  with  care,  testing  the  functions  and  sensitiveness 
of  the  joint  thoroughly,  employing  such  means  as  may  sug- 
gest themselves.  He  must  remember  that,  if  the  joint  be 
tender,  he  should  get  referred  pain  in  the  obturator  when- 
ever the  joint  surfaces  are  approximated.  There  should  be 
no  infiltration  in  the  periarticular  tissues.  Sometimes  one 
can  perceive  an  elastic  fullness  about  the  trochanter  or  be- 
low the  groin,  if  there  be  much  distension  of  the  capsular 
ligament.  Then,  there  must  be  a  history  of  acute  pain  and 
great  tenderness.  The  history  will  be  very  clear— the 
mother  being  able  to  name  the  day,  and  the  hour  frequent- 
ly,  as  I  have  said  before,  when  the  first  attack  of  pain  was 
experienced. 

The  Diagnosis  must  depend  upon  the  symptoms  and  signs 
already  enumerated.  There  are  peculiar  cases  of  bone 
disease  with  acute  invasions,  and  with  sudden  remissions. 
These  are  exceptional,  however,  and  I  am  quite  sure  that 
a  careful  study  with  opportunities  for  repeated  examina- 
tions, will  enable  one  to  arrive  at  a  diagnosis. 

The  Prognosis  is  good,  and  the  exceptions  to  a  perfect  re- 
covery are  very  few.  The  case  last  reported  is  an  excep- 
tion, and  the  case  of  a  boy  whom  I  saw  several  years  ago, 
and  placed  on  record  as  illustrating  an  irregular  type  of 


ACUTE  PRIMARY  SYNOVITIS.  I2Q 

' 

hip-disease,  seems  now,  on  retrospection,  to  have  been  one 
wherein  repeated  attacks  terminated  in  bone  disease  and 
abscess.  The  report  is  taken  from  a  paper  on  "The  Diag- 
nosis of  Hip-Disease,"  which  I  published  in  the  American 
Journal  of  the  Medical  Sciences,  in  October,  1878.  Since 
the  publication  of  that  paper,  this  case  has  been  under  the 
care  of  an  orthopedic  surgeon  of  this  city,  who  assures 
me  that  the  patient  is  now  in  the  third  stage  of  "hip-joint 
disease,"  and  is  under  the  extension  treatment.  The  case 
is  certainly  very  peculiar,  and  my  history  points,  as  I  have 
intimated,  to  recurring  attacks  of  synovitis,  the  final  one, 
as  in  many  instances  of  recurring  disease,  not  resolving 
well,  and,  in  addition  to  this,  invading,  contiguous  tissues. 
At  all  events,  I  shall  give  it  in  detail,  and  at  the  same  time 
with  this  regret,  viz.,  that  I  do  not  feel  that  confidence  in 
my  notes  of  1872-73 — the  earlier  years  of  my  hospital  ser- 
vice— that  I  feel  in  those  of  later  years.  My  records  were 
more  meagre  and  hence  my  "  facts"  were  not  well  enough 
fortified  against  criticism.  "No  signs  of  disease"  in  1873 
does  not,  for  instance,  carry  with  it  that  conviction  that  the 
same  expression  does  in  1877. 

In  the  month  of  July,  1877,  a  boy,  aged  eight  years,  was 
brought  into  the  office,  and  I  at  once  recognized  him  as  an 
old  patient  long  absent.  I  of  course  censured  the  mother 
for  neglect,  but  she  was  positive  in  asserting  that  at  her  last 
visit  three  years  ago  the  case  was  pronounced  cured;  so  on 
referring  to  the  books  I  found  a  record  of  the  diagnosis  April 
19, 1873,  as  "  hip-disease;  end  of  first  stage,"and  a  note  July 
i8th  same  year  "no  signs  of  disease."  At  this  visit  his  left 
thigh  is  flexed  on  pelvis  at  an  angle  of  135°,  and  is  rotated 
outward;  the  limb  is  in  fact  in  the  typical  position  for  the 
second  stage  of  "  hip-disease."  He  is  very  lame;  screams 
at  night,  waking,  as  it  were,  out  of  sleep,  and  in  the  morn- 
ing has  no  recollection  of  having  suffered  or  screamed 
during  the  night.  Refers  the  pain  by  day  to  the  parts  on 
either  side  of  the  patella;  there  is  no  swelling  or  tenderness 
around  hip  or  knee,  both  of  which  seem  peculiarly  free 
from  disease  so  far  as  external  appearances  or  handling 
are  concerned.  Flexion  and  abduction  can  be  made  with- 
out pain  or  resistance,  but  other  motions  are  limited  by 
muscular  action;  when  passive  motion  is  made  he  complains 
of  pain  at  the  knee.  There  is  no  spinal  tenderness,  no 
angular  deformity,  no  reliable  sign  of  vertebral  disease. 
The  mother  declares  that  the  boy  was  well  and  active  on 


130  DISEASES  OF  THE  HIP. 

the  isth,  five  days  before,  not  resting  well  the  night  of  the 
9th;  that  he  was  out  for  a  long  walk  on  the  i2th,  slept  well 
that  night,  and  on  rising  in  the  morning  was  lame,  but  was 
free  from  lameness  on  the  i4th  and  on  the  isth;  and  that  all 
of  the  present  signs  date  from  the  i6th.  Last  winter,  she 
reports,  he  had  very  nearly  the  same  train  of  symptoms  one 
day  after  a  storm,  and  recovered  spontaneously.  The  attack 
in  1873  had  lasted  two  or  three  months  prior  to  his  applica- 
tion here  for  treatment.  With  the  single  exception  of  the 
transient  lameness  of  last  winter,  just  mentioned,  he  is  re- 
ported to  have  been  absolutely  free  from  anything  like  hip- 
disease  since  July,  1873.  One  year  ago  he  had  pertussis 
without  any  recognizable  sequel. 

There  are  nine  children  in  the  family,  and  this,  the 
seventh,  is  the  only  one  ever  out  of  health,  so  claimed.  He 
was  always  considered  a  delicate  child  prior  to  the  spring 
of  1873.  A  severe  dentition,  with  an  occasional  convulsion, 
a  series  of  convulsions  when  two  years  of  age,  a  scarlatina 
shortly  thereafter,  and  rubeola  next  in  turn,  make  up  his 
personal  history.  He  is  now  fairly  nourished,  though  the 
four  lower  and  the  two  upper  incisors  are  distinctly  notched 
and  irregular,  while  two  molars  on  the  left  side  have  each 
six  distinct  processes.  The  mother  is  of  a  temperament 
markedly  nervous,  and  her  appearance  forcibly  suggests 
struma,  the  maternal  grandfather  died  of  "  rheumatic 
gout,"  the  grandmother  of  "apoplexy."  The  father  seems 
healthy,  and  gives  agood  family  history.  No  specific  taint 
is  discovered,  though  strongly  suspected  in  view  of  the 
presence  of  notched  teeth  in  the  child.  A  blister  and  poul- 
tices were  ordered  to  the  dorso-lumbar  spine. 

The  deformity  is  much  less  July  27th,  and  the  boy  feels 
better.  A  fourth  of  a  grain  of  the  extract  of  belladonna 
three  times  a  day  is  ordered.  The  treatment  now  is  direc- 
ted to  the  spine  more  as  a  solution  to  the  diagnosis  than  as 
a  therapeutical  measure.  It  will  be  remembered  that  I 
found  no  spinal  tenderness,  and  hence  I  had  no  good  rea- 
son for  considering  this  a  spinal  arthropathy.  The  mother 
calls  Angust  3d  to  report  the  child  free  from  pain,  and  the 
limb  perfectly  straight,  unless  after  exertion. 

On  the  nth  he  is  examined;  no  resistance  to  normal  mo- 
tion in  any  direction  found,  except  on  complete  extension. 
In  view  of  a  possible  syphilitic  element  in  the  etiology,  pot- 
ass, iodid.  gr.  iv.  three  times  a  day  is  ordered.  There  is 
scarcely  any  lameness  perceptible;  stands  with  limbs  par- 


ACUTE  PRIMARY  SYNOVITIS.  131 

allel;  contour  of  nates  normal;  motion  good  in  every  di- 
rection, though,  when  thigh  is  completely  flexed  on  abdo- 
men, he  complains  of  pain  at  the  knee. 

On  the  2oth  of  September,  flexion  and  extension  could 
be  made  to  extreme  limit;  rotation  inward  to  extreme  limit 
causes  the  boy  to  wince,  though  he  protests  against  feeling 
any  pain.  The  iodide  is  continued. 

On  the  i yth  of  October,  I  found  a  complete  relapse, 
which  the  father  attributes  to  a  strain  the  boy  received  last 
visit  on  the  way  home.  The  iodide  is  discontinued,  and 
the  belladonna,  in  fourth-grain  doses,  ordered  again.  A 
liniment  for  the  hip  is  likewise  prescribed. 

He  was  improving  again  on  the  7th  of  November,  at 
samer  ate  as  before. 

April  17,  1878. — Is  seen  to-day,  and  the  limb  is  found 
again  in  the  position  of  second  stage.  The  father  reports 
that  in  November  last  he  made  a  good  recovery  from  that 
attack,  and  has  been  straight  and  active  until  three  weeks 
ago,  when  present  relapse  appeared.  There  is  found  also 
to-day,  for  the  first  time,  dorsal  tenderness. 

THE  TREATMENT  with  which  I  have  been  most  familiar, 
and  to  which  the  symptoms  yield  with  great  promptness, 
is  blistering,  followed  by  poulticing.  The  hospital  cases 
respond  well  to  this  method,  and  hence  I  can  recommend 
it  with  much  confidence.  In  addition  to  the  testimony  in 
the  cases  above  mentioned,  take  the  following: 

A  girl,  aged  six  years,  was  admitted  to  hospital  Septem- 
ber 2d,  1870.  The  history  was  that  the  mother's  family 
was  consumptive,  but  that  this  child  had  been  in  perfect 
health  up  to  the  second  week  in  August,  two  weeks  before 
her  admission,  when,  without  any  known  cause,  unless  it 
may  have  been  a  fall  three  weeks  before  the  first  symptom, 
she  began  to  limp  and  to  complain  of  pain  in  right  knee 
and  hip.  She  soon  became  quite  helpless,  and  suffered  ex- 
cessively at  night.  The  appetite  failed,  and  she  lost  flesh 
rapidly.  Her  exact  condition  on  admission  is  not  recorded, 
but  it  is  noted  that  a  fly-blister  was  applied,  and  that  on 
the  7th,  four  days  later,  she  was  comfortable.  On  the 
8th  she  is  reported  as  resting  well  nights,  and  on  the 
i2th  "very  little  pain  "  is  noted.  On  the  ijth  it  is  stated 
that  she  "  came  in  totally  unable  to  walk,  but  can  now 
walk,  even  without  the  aid  of  chair;  right  leg  semiflexed 
and  everted  on  standing;  right  hip  broadened;  fold  of  natis 
much  lowered;  very  little  tenderness  either  behind  tro* 


132  DISEASES  OF  THE  HIP. 

chanter  or  in  groin,  but  considerable  on  concussion  of  hip 
through  trochanter;  limbs  equal  in  length."  On  the  2pth 
she  is  walking  with  a  very  slight  limp.  Two  weeks  later 
there  is  no  tenderness  anywhere.  Is  walking  without 
lameness,  and  is  growing  fat.  And  again  on  November 
i4th  no  tenderness  could  be  elicited  on  pressure  over, 
flexion  or  concussion  of,  the  joint.  She  was  under  observa- 
tion until  the  2oth  of  the  following  March,  and  no 
signs  of  any  disease  in  or  about  the  hip  manifested  them- 
selves. I  saw  her  early  in  November,  1880,  nearly  ten  years 
later,  and  could  find  no  evidence,  so  far  as  physical  signs 
went,  that  she  had  ever  had  any  disease.  During  all  this 
period  she  had  been  free  from  pain,  tenderness,  and 
lameness. 

A  word  regarding  blisters.  The  respected  founder  of 
the  Hospital  for  the  Ruptured  and  Crippled,  Dr.  James 
Knight,  attaches  great  importance  to  the  poultices  which 
we  employ  immediately  after  the  blistering,  and  the  mode 
of  procedure  is  this:  A  plaster  of  cantharidal  cerate,  three 
inches  by  four  or  five,  is  applied  over  the  trochanteric  re- 
gion at  night,  and  not  removed  until  the  following  morn- 
ing, when  the  blebs  are  pricked,  giving  vent  to  the  serum 
beneath,  and  a  large  poultice  of  flaxseed-meal  is  applied  to 
this  surface,  no  cloth  intervening.  The  poultice  is  renewed 
every  six  hours  for  two  or  three  days,  when  a  dressing  of 
simple  cerate,  or  other  similar  unguent,  is  employed  for  a 
few  days  longer,  the  healing  process  going  on  the  mean- 
while. 

We  do  not  find  it  necessary  to  enjoin  any  more  rest  than 
the  patient  will  necessarily  demand,  yet  I  have  a  friend  in 
Boston,  Dr.  E.  H.  Bradford,  a  recognized  authority,  who 
seemingly  places  much  value  on  absolute  rest,  citing  the 
following  very  instructive  case  in  the  Boston  Medical  and 
Surgical  Journal  for  November  u,  1880: 

"  A  healthy  girl,  five  years  old,  a  patient  of  Dr.  Tarbell's 
of  Boston,  was  suddenly  seized  with  extreme  pain  in  one 
limb.  There  had  been  no  prodromata,  except  that  the 
child  had  been  noticed  to  limp  a  few  weeks  before.  The 
pain  was  intense,  particularly  severe  at  night,  and  the 
patient  required  opiates.  The  slightest  jar  caused  violent 
pain.  The  pain  increased  for  a  week,  and  began  to  dimin- 
ish, but  was  aggravated  by  changing  the  sheets.  On  ex- 
amination the  child  was  found  lying  with  both  thighs 
flexed  and  abducted.  The  patient  could  move  the  toes  and. 


ACUTE  PRIMARY  SYNOVITIS.  133 

ankles,  and  such  slight  motion  of  the  knee  (the  patient  lay 
with  the  thighs  spread  apart  and  the  legs  bent  at  the  knee) 
as  did  not  move  the  thigh  was  possible,  but  any  motion 
disturbing  the  hip-joints  caused  intense  pain.  There  was 
no  fever,  and  none  of  the  other  joints  were  affected,  but 
there  was  swelling  and  tenderness  over  both  hip-joints.  As 
the  child  was  absolutely  immobilized  by  the  disease,  noth- 
ing mechanical  for  the  .purpose  was  tried.  Extension  was 
not  used,  as  the  pain  had  been  decreasing.  In  a  few  days 
this  had  diminished  greatly,  and  in  a  short  time  had  dis- 
appeared. In  a  month  the  patient  regained  perfect  motion 
at  the  left  hip-joint,  but  some  muscular  resistance  remained 
at  the  right  hip,  and  a  light  extension  by  weight  and  pul- 
ley was  applied.  In  three  months  the  child  walked  about 
freely,  and  six  months  later  she  was  considered  perfectly 
well  by  her  parents.'  There  has  up  to  this  time  been  no 
relapse." 

There  came  a  girl,  thirteen  years  of  age,  into  the  hospital 
in  September,  1873,  with  a  history  of  two  months'  lameness 
and  pain,  which  had  been  most  of  the  time  referred  to  the 
neighborhood  of  the  patella.  She  walked  with  a  very 
marked  limp,  and  the  left  limb,  the  lame  one,  was  appar- 
ently much  elongated.  There  was  much  flattening  of  the 
nates,  and  its  normal  contour  was  lost.  Sudden  pressure 
over  the  trochanter  caused  her  to  start  as  if  electrified. 
There  was  no  atrophy,  and  as  she  stood  the  limbs  were 
nearly  parallel. 

Her  symptoms  pointed  to  a  synovial  inflammation,  with 
probably  an  increased  joint  secretion.  A  liniment  and  a 
spica  bandage  constituted  the  treatment,  and  rest  was  not 
enjoined.  In  less  than  six  weeks  the  contour  of  the  hip 
was  restored,  all  lameness  had  disappeared,  the  functions 
of  the  joint  were  perfect,  and  the  patient  was  discharged 
cured.  A  relapse  has  never  occurred,  to  my  knowledge, 
and  I  have  had  an  opportunity  of  seeing  the  girl  from  time 
to  time. 

The  practical  deductions  from  this  chapter  are  that  acute 
primary  synovitis  is  a  comparatively  rare  disease,  that  it 
is  of  easy  management,  and  that  the  progress  is  toward 
recovery.  The  duration  is  from  two  to  six  or  eight  months, 
seldom  greater  than  four  months. 

In  giving  a  prognosis,  it  must  not  be  forgotten  that  bone 
disease  does  occasionally  arise  from  extension  of  the  inflam- 
mation from  the  synovial  membrane.  To  demonstate  this 


134  DISEASES  OF  THE  HIP. 

proposition  is  hardly  possible,  yet  the  histories  of  some 
cases,  especially  in  children  between  eight  and  twelve  years 
of  age,  furnish  strong  evidence.  We  do  not  know,  however, 
but  that  the  bone  lesion  may  have  begun  near  the  peri- 
phery and  that  an  exacerbation  was  early  induced.  The 
pathological  process  is  easy  of  explanation.  It  is  well 
then,  under  these  circumstances,  to  be  cautious  in  the  prog- 
nosis. 


CHAPTER  IX. 
I.  ACUTE  EPIPHYSITIS  OF  THE  HIP* — II.  TRAUMATIC 

DlASTASIS. 

In  selecting  the  term  epiphysitis  rather  than  that  of  dia- 
physo-epiphysitis,  I  feel  that  I  shall  evoke  some  criticism, 
and  in  advance  I  wish  to  state  that  my  reason  for  so  doing 
is  that  while  the  primal  lesion  is  at  the  diaphyso-epiphys- 
cal  junction,  the  ostitis  extends  the  more  quickly  and  the 
more  destructively  to  the  epiphysis,  so  that  a  necrotic  dias- 
tasis  soon  follows,  and  the  force  of  the  lesion  is  thus  practi- 
cally spent  upon  this  portion  of  the  femur.  The  few  patho- 
logical specimens,  to  which  I  have  had  access,  prove  to  my 
own  mind  that  even  where  the  diastasis  has  not  ensued,  the 
epiphysis  is  pretty  thoroughly  destroyed,  and  the  clinical 
signs  likewise,  convince  me  that  such  has  been  the  result 
of  the  inflammatory  process. 

A  class  of  cases  coming  under  my  observation  during 
the  past  few  years  has  been  peculiarly  puzzling,  and  occa- 
sionally a  ray  of  light  is  shed  upon  individual  cases.  Some 
I  have  at  first  diagnosticated — long  subsequent,  however, 
to  the  inflammatory  process — congenital  unilateral  disloca- 
tion; some  acute  suppurative  periarthritis;  some  syphilitic 
arthritis,  or  epiphysitis,  and  some  were  absolute  enigmas. 
To  the  lectures  of  a  friend  in  London,  Mr.  C.  Macnamara, 
I  am  indebted  for  my  first  venture  at  classification — not 
that  I  had  not  seen  the  term  employed,  yet  cases  were 
wanting  that  were  sharply  defined.  Clinical  pictures  were 
not  readily  attainable.  They  are  not  abundant,  yet  I  am 
convinced  that  many  cases  of  what  we  are  in  the  habit  of 
calling  acute  hip-disease,  cases  which  follow  closely  oh 
distinct  traumatism  with  acute  symptoms,  should  be  called 
acute  epiphysitis.  Occasionally  one  with  large  opportuni- 
ties for  clinical  material  comes  in  contact  with  just  such 
instances  of  bone  lesion,  where  not  only  the  initial  symp- 
toms are  acute,  but  where  the  whole  progress  of  the  disease 


136  DISEASES  OF  THE  HIP. 

is  acute  up  to  the  point  of  destruction  of  the  joint.  Prac- 
tically, often  the  same  results  are  reached,  yet  they  are  the 
more  speedily  reached,  and  all  the  so-called  stages  of  a 
joint  disease  pass  in  rapid  review. 

My  own  experience  is  confined  almost  exclusively  to  the 
disease  as  it  affects  young  children  and  infants,  but  Mr. 
Macnamara,  in  the  second  edition  of  his  lectures  on  Dis- 
eases of  the  Bones  and  Joints,  states  the  following  : 

"Acute  epiphysitis,  although  most  frequently  met  with 
among  young  children  under  two  years  of  age,  is  not  by  any 
means  confined  to  infant  life,  as  we  have  seen  from  the  cases 
already  detailed."  The  cases  he  has  recorded,  with  one  ex- 
ception, however,  were  those  in  which  other  epiphyses  than 
the  proximal  epiphysis  of  the  femur  were  involved. 

I  remember  seeing  a  few  years  ago  a  specimen  of  pecu- 
liar interest  to  the  orthopedist.  It  was  shown  me  by  Dr. 
Judson,  and  he  subsequently  presented  it  to  the  New  York 
Pathological  Society.  "  The  patient  was  eighteen  months 
old.  The  symptoms  commenced  suddenly,  and  ended  in 
death  from  exhaustion  in  seven  weeks.  The  child's  foot 
was  everted,  but  there  was  an  absence  of  the  reflex  symp- 
toms usually  found  in  hip-joint  disease.  An  examination 
showed  undue  mobility,  with  crepitation.  There  was  swell- 
ing in  the  iliac  fossa,  groin,  and  right  labium,  and  upper  part 
of  the  thigh.  An  incision  was  made  over  the  great  trochan- 
ter,  when  about  six  ounces  of  pus  escaped.  The  diagnosis 
made  was  separation,  partial  or  complete,  of  the  upper 
epiphysis  of  the  femur.  In  the  specimen  the  cartilage 
was  found  to  have  disappeared,  with  the  exception  of  a 
small  scale,  which  was  attached  by  its  outer  edge  to  the 
neck.  This  latter  was  a  rounded  fragment  of  cancellated 
tissue  three  eighths  of  an  inch  in  diameter."  The  extract  is 
taken  from  an  unofficial  report  of  the  society's  meeting  in 
the  New  York  Medical  Journal  December,  1878,  p.  628. 
Unfortunately,  a  complete  report  has  not  appeared  in  the 
Society's  Transactions,  as  the  specimen  was  presented  for 
a  candidate.  The  specimen  appears  to  me  to  be  one  of 
acute  epiphysitis  going  on  to  rapid  caries  necrotica.  Dr. 
Judson  tells  me  that  it  was  to  him  difficult  of  explanation. 
It  certainly  seems  to  have  been  the  result  of  a  rapid  process, 
and  the  clinical  history,  brief  as  it  is,  corresponds  closely 
with  one  of  a  case  that  came  under  my  own  observation 
after  the  acute  symptoms  had  passed. 

It  occurred  in  a  female  child,  who,  when  eight  and  a 


ACUTE  EPIPHYSITIS  OF  THE  HIP.  137 

half  months  of  age,  was  taken  with  a  cold  and  suffered  as 
a  consequence  apparently  from  grave  constitutional  symp- 
toms. The  febrile  reaction  was  very  great,  and  the  loss  of 
flesh  was  extreme.  The  mother  got  the  impression  that 
the  child  had  "  the  '  harmonia'  of  the  left  lung,"  and  at 
the  end  of  the  second  or  third  week,  just  as  a  change 
for  the  better  had  been  observed,  she  took  it  up  into  her 
arms  one  day,  when  the  discovery  was  made  that  the  hip 
was  very  tender,  and  that  swelling  in  the  groin  accom- 
panied this  tenderness.  This  fullness  of  the  groin  in- 
creased for  about  three  weeks  ;  the  skin  becoming  red, 
while  the  thigh  became  more  and  more  flexed.  Then  a 
physician  was  called,  and  he  regarded  it  as  abscess,  order- 
ing poultices,  which  were  continued  for  two  or  three  weeks 
longer.  The  abscess  soon  opened  spontaneously,  giving 
exit  to  about  a  half  teacupful  of  pus  "yellowish"  in  ap- 
pearance. The  parts  soon  healed  ;  the  infiltration  disap- 
peared, and  the  child  began  to  walk  around.  It  had  been 
walking  around  the  floor  by  the  chairs  nearly  six  weeks 
when  the  sickness  appeared,  and  had  not  shown  any  lame- 
ness. The  gait  now  was  marked  by  a  decided  lameness, 
which  continued  up  to  the  time  I  first  saw  the  case  eight 
months  afterwards — August,  1879. 

I  found  the  limb  from  a  half  to  three  quarters  of  an 
inch  shorter  than  its  fellow,  and  perceived  a  distinct  bony 
grating  with  upward  subluxation.  There  was  rotation 
outward,  and  the  lameness  was  such  as  one  would  expect 
from  a  diastasis.  The  movements  were  pretty  free  and 
unattended  with  pain  ;  a  cicatrix  in  the  groin  remained. 
The  teeth  were  irregular  and  decayed,  while  the  incisors 
were  notched,  though  not  in  the  crescentic  manner  that 
Hutchinson  describes.  I  naturally  suspected  a  specific  ele- 
ment in  the  case,  and  not  getting  satisfactory  evidence  in 
the  family  history  obtained,  took  the  patient  to  see  Dr. 
R.  W.  Taylor,  who,  after  a  very  thorough  examination, 
could  not  get  a  history  of  syphilis  in  either  father  or 
mother  (both  were  submitted  to  an  examination),  and  no 
traces  of  it  could  be  found  in  other  members  of  the  family. 
The  bony  grating  was  fully  recognized,  and  the  up-and- 
down  movement  he  stated  quite  positively  was  between 
the  diaphysis  and  the  epiphysis  ;  in  other  words,  his  diag- 
nosis was  a  diastasis  due  to  an  epiphysitis  caused  by 
cachexia. 

The  case  subsequently  came  under  the  care  of  Dr.  Robert 


138  DISEASES   OF  THE  HIP. 

Abbe,  who  recognized  the  same  condition  Dr.  Taylor  and  I 
had  recognized.  His  treatment  consisted  of  an  immovable 
apparatus  to  the  hip,  and  cod-liver  oil  with  iron.  This 
grating  grew  less  distinct,  Dr.  Abbe  informs  me;  but  the 
case  passed  out  of  his  hands,  and  neither  he  nor  I  have 
beenable  to  trace  it;  hence  my  inability  to  give  final  re- 
sults. 

In  the  cases  just  narrated,  the  facts  elicited  enable  one 
to  diagnosticate  epiphysitis,  remembering  the  case  of  Dr. 
Judson's.  The  grating  I  found  in  August,  eight  months 
after  the  beginning  of  the  inflammatory  process  and  about 
six  months  after  the  subsidence  of  the  same.  I  found  it 
again  quite  readily  on  two  different  occasions  in  November, 
while,  after  an  attempt  at  immobilization,  it  was  not  so 
easily  recognized — i.e.,  more  pain  was  induced  on  employ- 
ing the  movements  necessary  to  its  production.  The  case 
throws  considerable  light  on  some  of  those  reported  by 
Dr.  Sayre  in  the  second  edition  of  his  Lectures,  as  traumatic 
diastasis.  For  instance,  on  page  382  he  records  the  case  of 
a  little  girl  (age  and  date  of  injury  not  given),  in  which  he 
excluded  hip-disease,  although  there  was  a  large  abscess  in 
the  gluteal  region.  There  was  shortening,  the  trochanter 
was  above  Nelaton's  line,  while  "the  ordinary  symptoms  of 
luxation,  inversion  of  the  foot,  etc.,  when  the  head  of  the 
femur  is  upon  the  dorsum  of  the  ilium,  were  absent."  The 
accident,  we  learn  later,  had  occurred  two  years  before  (the 
date  of  Dr.  S.'s  examination),  and  the  shortening,  he  now 
learned,  had  followed  immediately.  "  The  abscess  [when  it 
came  and  how  long  it  lasted  we  are  not  informed]  was 
caused  by  inflammation  of  the  bursa  over  the  great  trochan- 
ter." On  page  384  another  case  is  recorded,  the  data  of 
which  are  more  exact.  The  child  was  three  years  old  when 
Prof.  Sayre  saw  it,  and  had  been  treated,  we  are  informed, 
for  eighteen  months  with  soap  liniment  and  a  bandage  for 
"a  simple  sprain,  then  six  months  in  St.  Luke's,  with  weight 
and  pulley,  for  hip-disease,  no  improvement  occurring  in  his 
hip."  At  the  end  of  these  two  years  the  little  patient  came 
to  Bellevue,  and  about  eight  months  afterwards  Dr.  S.  ob- 
tained the  following  history:  "When  three  months  old  the 
child  rolled  out  of  the  cradle,  and  the  mother,  catching  it  by 
the  leg  while  falling,  felt  something  snap.  Nothing  partic- 
ular was  noticed  until  about  a  week  afterwards,  when,  the 
mother  states  the  hip  looked  somewhat  swollen."  (The  italics 
are  my  own.)  Whether  this  swollen  condition  ever  termi- 


ACUTE  EPIPHYSITIS  OF  THE   HIP.  139 

nated  in  suppuration,  or  whether  a  cicatrix  was  sought 
when  the  patient  entered  Bellevue,  we  do  not  know. 

I  do  not  make  this  remark  to  be  hypercritical,  but  I  make 
it  because,  in  my  own  case,  a  surgeon  of  fine  diagnostic  abil- 
ity had  overlooked  the  cicatrix  in  the  groin,  had  discounted 
the  mother's  clear  testimony  about  the  swelling  and  the 
suppuration,  and  had  made  out  traumatic  "diastasis  of  the 
head  of  the  femur,  unquestionably,"  an  error  he  subse- 
quently very  frankly  admitted.  The  result  of  treatment  in 
the  two  cases  I  have  taken  from  Dr.  Sayre  is  not  given.  "  It 
was  the  same  as  if  he  had  hip-disease"  in  the  second;  not 
given  in  the  first. 

The  third  case  the  doctor  reports  is  on  pages  385  ft  seq. 
This  was  in  a  girl,  aged  four,  seen  January  5,  1873,  and  the 
history  he  obtained  was  that  on  Christmas,  1870,  the  child, 
already  six  months-  walking,  was  left  by  the  mother  for 
about  two  hours  in  charge  of  the  nurse,  and  on  the  mother's 
return  the  little  one  was  found  lame  in  the  left  leg,  which 
was  shortened  and  slightly  turned  out.  From  that  fatal 
hour  to  the  fifth  of  January,  1873,  the  child  was  not  "able 
to  walk  upon  it  or  touch  the  floor."  "  The  nurse  insisted, 
with  great  positiveness,  that  she  had  received  no  fall  or 
other  accident  during  the  mother's  absence,  and  that  she 
had  not  been  out  of  her  sight  a  single  moment."  In  view 
of  the  mother's  clear  recollection  of  the  signs  of  a  diastasis 
(after  the  lapse  of  two  years),  the  recorder  of  the  history 
could  make  no  other  comment  on  the  nurse's  statement  than 
he  did,  viz.,  "The  child  being  too  young  to  contradict  this 
statement,  it  has  to  be  received  for  what  it  is  worth."  This 
patient  was  then  living  in  London,  and  had  the  benefit  of 
the  advice  of  the  surgeons  connected  with  the  different  hos- 
pitals. All  of  the  surgeons  who  examined  the  patient  pro- 
nounced the  case  one  of  hip-disease,  and  advised  leeching, 
blistering  and  rest.  "The  limb  gradually  contracted;  ad- 
ducted  and  rotated,  until  in  the  course  of  the  year  it  assumed 
its  present  condition,"  which  is  shown  by  a  photograph,  and 
the  deformity  in  flexion  seems  to  be  rectangular,  with  rota- 
tion outward  over  a  quadrant.  Indeed,  such  is  the  descrip- 
tion on  page  387.  This  progressive  deformity  is  certainly 
inconsistent  with  "straight  limb,"  "spine  vertical,"  signs 
given  as  diagnostic  of  diastasis,  on  page  382.  A  false 
anchylosis  had  resulted,  too,  for  "  under  chloroform,  and 
with  some  force,  limited  movements  were  obtained." 

In  this  case,  we  are  informed,  there  had  been  "  no  suppur- 


140  DISEASES  OF  THE  HIP. 

ation  about  the  joint,  abscesses,  or  other  evidences  of  carious 
disease  of  this  articulation."  The  result  of  the  treatment 
(division  of  muscles  and  tendons  aiming  at  correction  of  de- 
formity under  chloroform,  and  subsequent  use  of  apparatus) 
is  such  as  one  would  expect  in  a  case  of  caries  sicca  of  the 
hip;  and  hence  I,  for  one,  am  not  convinced  that  this  was  even 
a  case  of  diastasis,  either  from  trauma  or  acute  epiphysitis. 

It  is  far  from  my  intention  to  deny  the  existence  of  a 
traumatic  diastasis,  or  to  detract  in  the  least  from  the  honor 
due  the  distinguished  Bellevue  Professor  in  bringing  this 
subject  so  prominently  forward  in  surgical  science.  It 
leaves,  as  he  claims,  one  of  the  deformities  to  be  differentiated 
from  that  of  chronic  ostitis  of  the  hip.  Only,  my  own  studies 
lead  me  to  regard  it  as  an  extremely  rare  accident  in  early 
childhood,  and  as  resulting,  when  it  does  result,  from  morbid 
processes  going  on  at  the  diaphyso-epiphysial  junction. 

There  is  a  very  interesting  case,  with  a  pathological  speci- 
men, on  pages  389  and  390,  valuable  not  so  much  on  account 
of  the  specimen,  which  might  be  found  in  connection  with 
a  chronic  ostitis  wherein  repair  had  taken  place,  but  on 
account  of  the  testimony  of  the  physician  who  gave  Dr. 
Sayre  so  clear  a  history  of  the  case  seen  the  day  following 
the  accident.  There  was  something  here  that  seemed  tangi- 
ble— the  shortening,  the  adduction,  and  the  outward  rota- 
tion. Yet  the  physician  diagnosticating  diastasis  at  this 
time  should,  it  seems  to  me,  have  made  some  mention,  pos- 
itive or  negative,  of  crepitus,  either  bony  or  cartilaginous. 

Occasionally  one  meets  with  a  case  many  months  after 
the  subsidence  of  all  inflammatory  signs,  and  fails  to  find  any 
grating.  This  can  be  easily  explained  by  the  repair  which 
takes  place,  leaving  the  remnant  of  the  epiphysis  covered 
with  a  smooth  cartilaginous  capsule  moving  in  a  new 
cavity,  such  as  Dr.  Sayre's  specimen  showed.  The  presence 
or  absence  of  roughening  will  depend,  of  course,  on  the 
kind  of  repair  that  has  taken  place. 

In  the  early  summer  of  1878,  a  male  child  ten  months  of 
age  came  under  my  care  fora  cellulitis  of  the  upper  fourth 
of  the  left  thigh.  The  infiltration  was  a  notable  feature  of 
the  case,  the  skin  being  quite  tense,  yet  presenting  no 
acumination.  There  was  much  febrile  reaction  and  con- 
siderable anorexia.  The  child  would  make  no  attempt  to 
creep,  and  would  lie  only  on  the  right  side.  Four  weeks 
previously  the  mother  had  observed  one  morning  a  sudden 
"loss  of  power"  in  the  limb,  and  could  not  recall  any  in- 


ACUTE  EPIPHYSITIS  OF  THE  HIP.  14! 

jury  direct  or  indirect.  Next  day  the  fever  appeared  and 
with  it  a  "  little  swelling"  about  the  thigh.  This  continued 
without  abatement  to  the  date  when  I  first  saw  the  case. 

I  ordered  an  anodyne  and  poultices.  Four  days  later  I 
saw  the  child  and  found  its  condition  about  the  same. 
Seven  days  after  this  visit  I  found  the  infiltration,  which 
had  involved  only  one  side  of  the  thigh,  filling  both  sides, 
and  extending  up  to  the  crest  of  the  ilium,  the  thigh  circum- 
ference being  thirteen  and  a  half  inches  against  eight  for 
corresponding  portion  of  the  other  limb.  The  superficial 
veins  were  large  and  tortuous,  and  I  detected  a  small  area 
of  deep  fluctuation.  Fearing  either  a  malignant  or  a 
syphilitic  disease  I  refrained  from  incising.  The  anodyne 
no  longer  gave  relief,  and  I  resorted  to  stimulants,  as  they 
seemed  to  be  indicated,  and  concluded  to  wait  a  little 
longer. 

I  did  not  have  an  opportunity  of  seeing  the  little  patient 
again  until  the  last  of  July,  five  weeks  having  intervened. 
In  this  interval  another  physician  had  been  consulted,  and 
he  opened  the  abscess,  for  such  it  proved  clearly  to  be,  in  a 
week  or  two  after  I  had  last  seen  the  case,  giving  exit,  the 
mother  states,  to  four  glassfuls  of  pus.  This  gave  the 
needed  relief,  and  the  child  was  now  free  of  pain,  although 
there  was  some  tenderness  on  moving  the  hip.  There  was 
still  a  certain  amount  of  infiltration.  A  tonic  was  ordered, 
and  nine  days  later  I  found  the  inguinal  glands  much  en- 
larged, the  infiltration  above  mentioned  presenting  a  boggy 
feel,  while  the  motion  at  the  hip  was  smooth.  A  firm  roller 
was  applied,  and  as  the  patient  was  greatly  emaciated  I 
urged  that  it  be  taken  out  on  the  water  frequently.  I  was 
much  surprised  to  find  a  month  afterwards  one  inch  short- 
ening of  the  limb,  and  signs  of  a  pathological  dislocation. 
The  case  soon  passed  from  under  observation,  and  at  the 
end  of  a  year  I  succeeded  in  tracing  it  out,  to  find  the  limb 
everted  to  a  slight  degree,  the  trochanter  on  a  higher  plane 
than  that  of  the  opposite  side — one  inch  above  Nelaton's 
line — and  nearer  the  anterior  superior  spine  of  the  ilium, 
no  rounded  body  like  that  of  the  head  of  the  bone  lying  on 
the  dorsum,  and  no  bony  grating  on  active  or  passive 
motion,  both  of  which  could  be  made.  There  were  three 
quarters  of  an  inch  shortening  which  could  be  easily  over- 
come by  traction.  This  speedily  recurred  on  desisting  from 
the  traction.  There  was  only  a  half  inch  atrophy  of  the 
limb,  and  the  infiltration  was  no  longer  present.  The 


142  DISEASES  OF  THE  HIP. 

mother  had  been  dead  six  months,  dying  from  consump- 
tion of  two  years'  duration.  The  father  did  not  care  for 
any  further  treatment,  and  hence  none  was  ordered.  I 
examined  the  case  purely  scientifically  a  year  afterwards,  to 
find  this  time  one  inch  shortening  and  one  inch  atrophy. 
The  gait  and  deformity  were  the  same  on  the  occasion  of 
my  last  examination,  fourteen  months  having  elapsed.  The 
shortening  was  one  and  a  quarter  inches,  and  not  overcome  by 
traction. 

It  will  be  seen,  then,  that  a  year  elapsed  between  the  sup- 
purative  period  and  my  next  observation.  Whether  there 
ever  existed  any  bony  grating  I  did  not  know,  yet  the  pre- 
sumption is  that  such  was  present  before  the  reparative 
process  was  fully  established.  If  there  is  one  thing  more 
clearly  demonstrated  than  another  in  bone  diseases  it  is 
the  wonderful  success  Nature  meets  with  in  reproducing 
osseous  and  cartilaginous  material.  Many  of  Dr.  Sayre's 
cases  of  excision  have  demonstrated  this  most  conclusively. 
In  the  frontispiece  of  his  last  edition  is  a  specimen  most 
remarkable  in  this  respect. 

The  diagnosis,  then,  of  acute  epiphysitis  rests  chiefly 
upon  the  following  points:  The  age  of  the  patient,  viz., 
under  two  years  of  age.  (This  is  not  absolute,  only  my  own 
experience  induces  me  to  name  this  period.  Other  ob- 
servers have  met  with  this  lesion  in  older  children.)  The 
accuteness  of  the  attack,  coming  on  rather  suddenly,  and 
ushered  in  by  marked  constitutional  disturbance.  The 
history  of  exposure  to  cold  or  of  atraumatism.  The  gravity 
of  the  symptoms  during  the  first  fortnight.  The  early 
signs  of  suppuration.  The  loss  of  function  of  the  limb 
almost  from  the  first  symptom,  with  extreme  tenderness  of 
the  joint  and  periarticular  tissues.  The  resulting  deformity, 
viz.,  that  of  a  diastasis  with  grating  felt  in  connection  with 
the  femur  itself.  This  grating  is  not  a  constant  sign, 
especially  if  repair  has  begun  before  examination  is  made. 
The  lesion  is  to  be  differentiated  from  syphilitic  periostitis 
of  the  epiphysis  and  diaphysis,  from  traumatic  diastasis, 
from  acute  periarthritis,  from  acute  synovitis,  and  from 
chronic  articular  ostitis  with  acute  exacerbation. 

In  syphilitic  disease  there  is  always  the  history,  which, 
by  the  way,  is  not  always  easily  obtained.  The  symptoms 
of  hereditary  syphilis  are  so  changeable  and  so  uncertain 
that  one  cannot  always  decide  the  question.  One  group  of 
symptoms  will  satisfy  one  authority  in  syphilography  and 


ACUTE  EPIPHYSITIS  OF  THE  HIP.  143 

7* 

not  satisfy  another.  The  mere  notching  of  the  teeth  is  far 
from  conclusive  as  a  sign  There  must  be  a  regularly  cres- 
centic  notching  for  the  Hutchinson  teeth,  and  then  even 
with  this  clean-cut  sign  some  are  unwilling  to  accept  it  as 
evidence  unless  the  wedge-shaped  teeth  be  present. 

The  following  case  well  illustrates  the  difficulty  of  a  dif- 
ferential diagnosis: 

Dr.  S.  Hemingway  referred  to  me  in  October,  1879,  a 
female  child,  aged  eighteen  months,  with  marked  infiltra- 
tion throughout  the  whole  extent  of  the  right  thigh,  the  cir- 
cumference being  ten  inches  against  seven  and  a  half  for 
the  opposite  side.  The  limb  was  held  flexed  without  any 
rotation  either  way,  and  on  employing  passive  motion  at 
the  hip,  a  distinct  bony  grating  could  be  felt  in  the  joint. 
The  upper  incisors  were  notched,  and  seemed  to  me  suf- 
ficiently crescentic  in  the  notching  ;  the  post-cervical  glands 
were  enlarged  symmetrically,  and  the  rectal  temperature 
was  103°.  I  could  not  find  any  condylomata,  but  there 
was  an  eczema  over  the  lobe  of  the  left  ear.  The  child 
was  very  thin,  and  poorly  nourished.  I  learned  that  one 
month  previously  the  little  girl  was  running  about  quite 
actively,  and  that  within  three  weeks  a  lameness  had  ap- 
peared. Whether  the  lameness  was  sudden  or  was  preceded 
or  accompanied  by  pain  I  did  not  learn.  At  all  events, 
the  child  now  would  not  make  any  attempt  to  walk. 

Without  making  any  attempt  to  get  a  specific  history  in 
the  parents,  I  referred  the  case  back  to  Dr.  Hemingway,  ad- 
vising an  antisyphilitic  treatment.  Eleven  days  later  Dr. 
H.  sent  the  child  to  me  again,  with  a  note  stating  that  the 
patient  failed  to  improve  under  the  mixed  treatment,  and 
that  then  he  had  applied  poultices  to  the  parts  with  decided 
benefit.  He  further  wrote  that  he  could  not  get  any  spe- 
cific history. 

I  somehow  felt  that  there  must  be  such  an  element  in  the 
case,  and  made  an  appointment  to  meet  the  Doctor  with 
Dr.  R.  W.  Taylor.  At  this  visit  the  grating  was  distinct, 
and  twelve  days  afterward  I  could  not  detect  it.  Emacia- 
tion had  now  become  extreme,  and  there  was  a  wrinkled, 
aged  appearance  of  the  face.  The  infiltration  had  not  de- 
veloped into  abscess,  but  nevertheless  seemed  to  have 
increased  in  extent. 

Next  day  we  met  Dr.  Taylor  in  consultation,  the  parents 
being  also  present,  and  he  failed,  after  a  most  exhaustive 
examination,  to  get  any  evidence  of  syphilis  in  either  pa- 


144  DISEASES  OF  THE  HIP. 

rent,  or  in  any  of  the  other  children.  On  the  strength  of 
this  negative  testimony  he  excluded  syphilis,  and  made  the 
lesion  out  a  purely  strumuous  periarticular  ostitis.  The 
grating  was  not  present  at  this  examination,  and  hence  his 
exclusion  of  joint  lesion.  Under  syrup  of  the  iodide  of  iron 
and  cod-liver  oil  the  patient  improved  so  much  that,  at  the 
end  of  six  weeks  the  infiltration  had  almost  completely  dis- 
appeared. 

Two  months  prior  to  this  examination  the  right  thigh 
was  five  and  a  quarter  inches  larger  in  circumference  than 
the  left.  Now  it  was  only  one  inch  larger.  The  limbs  now 
were  equal  in  length,  and  the  child  was  walking.  In  Feb- 
ruary, 1880, 1  saw  the  patient  again  and  detected  a  limp  not 
unlike  that  of  chronic  joint  disease.  While  all  movements 
were  painless  and  unresisted,  I  felt  the  grating  within  the 
joint  quite  distinctly.  The  capsular  ligament  seemed  ab- 
normally lax,  and  the  great  trochanter  was  more  prominent 
than  its  fellow.  A  few  days  later  I  found  a  half-inch 
shortening,  while  the  limbs  were  equal  in  size. 

I  did  not  see  the  case  again  until  October,  1882,  when 
I  found  a  practical  dislocation  of  the  hip  with  one  inch 
atrophy  of  the  thigh,  one  and  a  half  inches  shortening, 
and  the  grating  still  present  on  passive  motion.  Then 
again,  in  1883,  March  8th,  I  examined  the  limbs,  finding 
them  parallel  as  the  child  lay  on  the  table,  but  the  left  one 
was  rotated  outward  over  at  least  a  quadrant.  The  tip  of 
the  trochanter  was  an  inch  above  Nelaton's  line,  and  was 
on  a  plane  nearer  the  abdominal  walls  than  its  fellow.  The 
motions  were  still  good,  save  that  of  abduction.  External 
and  internal  rotation  were  preternaturally  free.  The 
shortening  was  one  and  a  quarter  inches,  and  only  a  quar- 
ter of  an  inch  could  be  gained  by  traction.  What  seemed 
to  be  the  remains  of  the  head  of  the  bone  (the  body  was 
small  and  irregular  in  shape)  could  be  felt  on  the  dorsum 
and  without  the  acetabulum,  though  if  sharp  flexion  were 
made  this  body  seemed  to  slip  into  the  acetabulum  with 
a  roughened  thud-like  sensation.  No  abscess  has  ever 
appeared. 

I  have  detailed  this  case  at  considerable  length,  indeed 
all  I  have  repeated  have  been  thus  extensively  narrated  in 
order  that  deductions  as  to  the  diagnosis  and  prognosis 
might  be  drawn.  In  this  particular  case,  however,  without 
a  history  even  of  syphilis,  I  am  still  strongly  inclined  to 
the  belief  that  the  lesion  was  syphilitic.  It  will  be  seen, 


ACUTE  EPIPHYSITIS  OF  THE  HIP.  145 

though,  that  the  presence  of  a  clear  history  is  necessary  to 
the  differentiation  of  epiphysitis  from  syphilitic  diseases  of 
the  bone. 

In  diastasis  of  traumatic  origin  the  history  is  also  the 
one  point  on  which  a  diagnosis  can  be  based.  There 
must  be  sudden  lameness  and  deformity  immediately  fol- 
lowing the  injury,  and  if  these  follow  any  acutely  inflam- 
matory symptoms  attended  with  suppuration,  leading 
questions  in  securing  the  history  should  be  avoided.  In 
diastasis  the  grating  should  also  be  recognized  early,  and 
of  course,  must  not  be  expected  after  the  lapse  of  many 
weeks. 

In  acute  periarthritis  the  infiltration  can  be  recognized, 
and  the  joint  is  free  from  tenderness.  The  joint  should  be 
tested  as  to  its  functions  from  time  to  time.  I  am  fully 
aware  that  a  satisfactory  test  of  the  joint  or  its  functions, 
if  an  acute  periarthritis  be  present,  is  exceedingly  difficult, 
and  as  the  treatment  is  practically  the  same  in  either  event, 
a  differential  diagnosis  can  be  deferred  until  the  subsidence 
of  the  acute  symptoms. 

From  the  acute  exacerbation  of  a  chronic  articular  ostitis 
the  history  will  be  all  important,  and  in  the  absence  of  this 
the  age  of  the  child,  the  character  of  the  infiltration,  and 
the  temperature  will  serve  in  all  likelihood  to  effect  the 
differentiation. 

Then  there  are  iliac  abscesses  and  perinephritic  inflam- 
mations that  may  harass  one,  yet  these  have  signs  quite 
distinctive,  and  scarcely  need  be  mentioned  in  this  connec- 
tion. 

The  prognosis  depends  largely  upon  the  cachexia  of  the 
child,  and  upon  the  gravity  of  the  lesion.  In  a  violently 
active  inflammation,  like  that  in  the  case  of  Dr.  Judson's 
patient,  the  chances  of  life  are  small.  Yet,  in  the  majority 
of  instances  death  does  not  ensue.  The  deformity  which 
results  is  pretty  uniform,  and  one  must  expect  from  a  half- 
inch  to  an  inch  shortening.  The  extension  to  the  surround- 
ing bones  does  not  often  occur,  yet  the  diaphysis  and  the 
whole  shaft  may  become  involved  in  an  osteo-myelitis,  the 
prognosis  of  which  is  grave  enough.  A  progressive  defor- 
mity, such  as  one  would  expect  in  chronic  ostitis  of  the 
hip,  is  not  to  be  expected. 

The  treatment  naturally  divides  itself  into  measures  for 
controlling  the  inflammation  of  the  early  stage,  and  means 
for  preventing  deformity  and  correcting  the  same. 


146  DISEASES  OF  THE  HIP. 

The  nature  of  the  disease  (to  use  an  expression  which  can 
never  become  too  hackneyed),  once  being  recognized,  the 
limb  should  be  placed  at  rest  in  the  position  which  will 
secure  the  most  comfort,  and  hot  or  cold  applications  em- 
ployed, according  to  the  taste  of  the  practitioner.  As  I  have 
before  remarked,  when  speaking  of  acute  inflammations 
my  own  preference  is  for  hot  fomentations.  If  abscess 
forms,  it  should  be  opened  early  and  destruction  to  the 
periarticular  structures  thus  avoided.  Undoubtedly  much 
valuable  information  can  be  gained  by  exploring  with  one's 
finger,  the  abscess  sacs  thus  opened.  Rest  should  still  be 
continued,  let  the  joint  be  well  protected  during  Nature's 
efforts  at  repair,  and  by  no  means  allow  the  patient  to  walk 
upon  the  limb,  unless  this  precaution  have  been  secured. 
I  am  not  giving  the  treatment  as  I  practiced  it,  but  I  am 
giving  such  as  my  cases  teach  should  be  employed.  They 
did  not  have  any  protection  to  the  joint  except  in  one  in- 
stance, and  that  seemed  to  do  well.  Though,  in  a  case 
reported  by  Mr.  Macnamara  on  page  79  of  his  work,  to 
which  reference  has  been  made,  all  the  precautions  were 
taken,  drainage  tubes  were  inserted  about  the  joint,  and 
the  limb  was  fixed  to  a  Thomas'  splint  with  subsequent  ex- 
tension from  the  foot  of  the  bed.  The  final  report  records 
shortening,  and  such  other  conditions  as  my  own  cases 
show. 

A  plaster-of-Paris  dressing  or  a  well-moulded  leather 
splint  could  be  easily  managed,  I  should  think,  in  a  child 
so  young. 

These  need  to  be  worn,  too,  for  many  months  at  least, 
and  then  should  not  be  removed  until  the  joint  is  carefully 
examined  as  to  the  repairs  that  have  taken  place. 

II. 

DIASTASIS  OF    THE  HEAD  OF  THE  FEMUR. 

Diastasis  is  an  anglicized  Greek  term,  and  means  simply 
a  separation,  in  connection  with  the  proximal  end  of  the 
femur.  It  means  a  separation  of  the  epiphysis  from  the 
diaphysis,  and  corresponds  closely  enough  for  the  practical 
purpose  of  a  definition  with  an  intracapsular  fracture 
which  occurs  in  the  adult.  It  will  be  remembered  that  os- 
sification between  the  diaphysis  and  epiphysis  is  not  com- 
plete before  the  twentieth  year  of  life.  By  reference  to 
Fig.  7  on  page  47  the  line  of  cartilaginous  union  is  seen. 


DIASTASTS  OF  THE   HEAD   OF  THE   FEMUR.        147 

Dr.  Hamilton  classifies  epiphysial  separation  with  frac- 
tures, and  states,  in  speaking  of  them  as  applied  to  all  the 
long  bones,  that  they  rarely  occur  after  the  twentieth  year  of 
life;  and  in  speaking  of  this  particular  separation,  on  page 
374  of  "  Fractures  and  Dislocations,"  he  states  that  the  four 
cases  he  has  collected,  viz.;  one  reported  by  Mr  South  in 
1837,  in  a  boy  ten  years  of  age;  one  by  Dr.  Willard  Parker 
in  1850,  diagnosticated  seven  years  after  its  occurrence,  in  a 
girl  eighteen  years  of  age;  one  by  Dr.  Alfred  C.  Post  in  1840, 
in  a  girl  sixteen  years  old,  and  one  by  himself  in  a  boy  fifteen 
years  old,  "constitute  the  only  examples  of  this  accident 
which  I  find  reported,  or  of  which  I  have  any  knowledge,  and 
although  there  may  be  much  reason  to  suppose  that  the 
diagnosis  may  be  correct  in  each  instance,  I  can  not  regard 
them  as  actually  proven."  And  he  further  remarks,  "  nor 
can  I  admit  the  accident  as  fairly  established,  or  the  diag- 
nostic signs  as  being  properly  made  out  until  these  im- 
portant points  have  received  the  confirmation  of  at  least  one 
dissection." 

The  signs  given  by  Bauer  are:  eversion  of  the  limb  and 
shortening,  yet  the  limb  will  be  straight;  a  loose  articula- 
tion, a  straight  pelvis,  and  crepitus  in  the  early  stage;  the 
spine  will  be  vertical,  shoulders  square,  and  the  apex  of  the 
great  trochanter  above  Nelaton's  line.  The  deformity  must 
also  be  produced  suddenly.  If  one  confines  himself  to  these 
signs  the  diagnosis  should  be  easily  made,  and  no  two  ob- 
servers should  disagree.  For  at  least  ten  years  I  have  been 
looking  for  a  case  of  unmistakable  diastasis,  the  direct  result 
of  trauma,  and  I  must  confess  that  I  have  met  with  only 
a  single  case  that  does  not  admit  of  doubt.  This  was  in  a 
boy  eight  years  of  age,  whom  I  saw  for  the  first  time  the 
3cth  of  August,  1881.  He  was  able  to  walk,  though  he 
was  quite  lame,  and  the  act  gave  much  pain  referred  to  the 
left  hip.  There  was  an  inch  shortening,  and  this  yielded 
three  quarters  of  an  inch  on  strong  traction,  a  marked  bony 
crepitation  accompanying  this  manoeuvre.  There  was  a 
distinct  up-and-down  movement.  The  limb  as  he  stood 
was  very  nearly  on  a  line  with  the  axis  of  the  body,  but 
was  rotated  outward  over  an  arc  of  about  20°,  the  foot  being 
in  marked  eversion.  Most  of  the  weight  was  thrown  upon 
the  right  limb.  The  movements  were  very  good.  He 
complained,  the  father  said,  much  of  pain  during  the  night. 
There  did  not  seem  to  be  any  atrophy,  though  comparative 
measurements  were  omitted. 


148  DISEASES  OF  THE  HIP. 

The  history  as  given  by  both  the  patient  and  the  father 
was  that  three  weeks  before  this  date,  while  in  perfect 
health  and  sound  in  limb,  he  fell  a  distance  of  fifteen  feet, 
striking  directly  upon  the  left  hip.  His  lameness  and  ap- 
parent shortening  followed  immediately.  My  diagnosis  was 
diastasis  of  traumatic  origin,  and  the  case  was  referred  to 
Bellevue  Hospital  for  treatment.  Dr.  L.  E.  Holt,  who  was 
house-surgeon  to  the  fourth  surgical  division,  reported  to  me 
that  my  diagnosis  was  confirmed  at  the  hospital,  that  the 
deformity  was  reduced,  and  that  the  plaster-of-Paris  dress- 
ing had  been  employed. 

He  remained  under  treatment  from  September  ist  to 
November  2d,  when  he  was  discharged  cured.  I  traced  the 
case,  and  examined  again  on  the  loth  of  March,  1883,  find- 
ing a  little  broadening  of  the  hip,  about  the  trochanter,  on 
the  left,  the  affected  side,  perfect  motion  in  all  directions,  a 
half-inch  shortening  as  measured  from  both  trochanter  and 
umbilicus,  a  half-inch  atrophy  of  the  thigh,  a  quarter-inch 
of  the  calf,  and  a  gait  in  which  one  could  on  close  inspec- 
tion detect  a  slight  limp.  There  was  no  grating  or  rough- 
ening of  any  kind  within  the  joint.  The  recovery  may  be 
said  to  have  been  perfect. 

In  Mr.  South's  case,  as  quoted  by  Dr.  Hamilton,  the  limb, 
when  first  seen  after  the  accident  was  slightly  turned  out, 
but  scarcely  at  all  shortened.  If  the  thigh  were  flexed  and 
rotated  outward  a  distinct  "  dummy"  sensation  was  felt,  as 
if  one  articular  surface  had  slipped  off  another.  By  way 
of  treatment  the  patient  was  placed  on  a  double  inclined 
plane,  but  so  little  inconvenience  was  experienced  that  he 
would  frequently  leave  the  bed  and  walk  about.  The  fur- 
ther progress  of  the  case  has  not  been  recorded.  Dr.  Parker, 
at  his  clinic,  made  out  a  case  in  a  girl  who  had  had  abcess  and 
fistulous  discharge.  The  history  of  the  fall  on  the  curb- 
stone several  years  before,  although  in  time  followed  by  sup- 
puration, shortening  and  eversion,  and  the  fact  that  flexion 
and  rotation  could  be  made  without  inconvenience  seemed 
to  have  convinced  Dr.  Parker  of  the  correctness  of  his  diag- 
nosis. There  are  so  many  cases  of  undoubted  bone  disease  at 
the  hip  in  which  anchylosis  is  not  present  and  in  which 
flexion  and  rotation  cause  no  inconvenience,  that  Dr.  Hamil- 
ton was  fully  justified  in  not  accepting  this  clinic  case  as 
one  of  diastasis. 

Dr.  Post's  case  presented  the  signs  the  day  following 
the  injury,  and  Dr.  Hamilton's  case  was  equally  well  ob~ 


DIASTASIS   OF  THE  HEAD  OF  THE  FEMUR.         149 

served.  Still,  the  dissection  was  wanting,  and  hence  the 
diagnosis  has  not  been  verified. 

It  is  very  curious  how  much  difficulty  in  diagnosis  arises. 
Indeed  it  is  no  easy  lesion  to  make  out,  and  the  following 
case  illustrates  very  well  the  point  I  now  maintain. 

On  the  4th  of  December,  1880,  a  German  lad,  sixteen 
years  of  age,  presented  at  my  clinic,  and  there  was  found  a 
peculiar  deformity  about  the  hip,  which  he  said  had  imme- 
diately followed  a  fall  nine  months  before.  The  history 
was  confusing  a  little  and  I  saw  the  father  a  week  later,  who 
assured  me  that  one  day  in  March  last  the  boy  was  walk- 
ing rapidly  along  the  sidewalk,  when  he  slipped  and  fell, 
making  strong  effort  to  save  himself.  On  coming  into  the 
house  Jthe  boy  found  himself  hurt  so  severely  that  he  took 
to  his  bed,  and  was  unable  to  walk  for  six  weeks.  During 
this  period  he  was  treated  with  a  plaster-of-Paris  dressing 
for  a  "fracture  of  the  hip."  On  coming  out  of  this  treat- 
ment at  the  end  of  the  six  weeks,  he  hobbled  about  on  a  cane 
for  a  few  weeks  longer.  He  had  been  slowly  gaining  from 
that  time,  and  on  examination  there  was  found  an  inch  and 
a  half  atrophy  of  the  thigh,  undue  prominence  of  the  tro- 
chanter,  a  moderate  amount  of  limitation  in  all  the  joint 
movements,  and  at  least  an  inch  shortening  of  the  limb. 
The  limb  was  very  nearly  parallel  with  its  fellow,  and 
there  was  no  in  or  eversion.  I  did  not  get  enough  facts 
for  a  diagnosis,  and  I  thought  it  a  subluxation,  a  diastasis, 
or  an  arthritis.  The  case  was  sent  to  Dr.  Frank  H.  Hamilton, 
who  wrote  me  that  he  thought  it  a  "  fracture  of  the  neck, 
probably  a  separation  of  the  epiphysis."  Dr.  Holt,  who  was 
house-surgeon  at  Bellevue  at  the  time,  reported  to  me  on 
the  evening  of  the  8th  of  December  that  Dr.  Hamilton 
examined  the  case  more  carefully  that  day  in  the  hospital, 
in  the  presence  of  Dr.  Yale  and  Dr.  L.  H.  Sayre,  all  three  of 
whom  pronounced  it  an  intracapsular  fracture.  Dr.  Holt 
went  over  the  case  again  and  felt  convinced  that  such  was 
the  lesion. 

A  fortnight  later  Dr.  Hamilton  told  me  that  he  had 
changed  his  diagnosis  and  in  the  absence  of  a  more  satisfacr 
tory  history  could  not  believe  it  other  than  a  "genuine  case 
of  hip  disease." 

Now,  I  have  given  the  above  details  in  order  to  show 
how  uncertain  one  can  be  on  this  subject,  and  how  obscure 
signs  may  be  after  the  lapse  of  a  few  months. 

Histories  are  very  uncertain  bits  of  literature,  and  the 


150  DISEASES  OF  THE   HIP. 

facility  with  which  a  history  to  suit  a  case  can  be  obtained 
is  a  well-established  fact  in  medicine. 

Two  years  ago  I  had  a  friendly  correspondence  with  Dr. 
Sayre,  about  a  patient  he  sent  me  for  mechanical  support. 
The  patient  was  a  girl  fourteen  years  of  age  who  brought 
a  card  from  the  Doctor,  saying  this  was  a  very  interesting 
case  of  dislocation  of  the  hip  of  long  standing.  I  naturally 
felt  curious  to  "look  it  over,"  and  found  her  walking 
quite  easily,  though  limping.  The  heel  of  the  left  foot 
lacked  an  inch  of  reaching  the  floor,  and  the  foot  was  a 
little  everted.  The  limb  was  very  nearly  parallel  with  its 
fellow;  the  trochanter  could  be  felt  at  a  point  a  little  be- 
low the  crest  of  the  ilium,  and  near  the  anterior  superior 
spinous  process.  Taking  this  as  a  bearing,  I  ran  my  fin- 
ger over  it  and  encountered  a  globular  body  lying  on  the 
dorsum  ilii.  On  rotating  the  limb,  this  body  rolled  under 
my  finger.  In  the  dorsal  decubitus,  the  shortening  by  careful 
measurement  was  a  little  less  than  one  and  a  half  inches, 
and  on  firm  traction  downward  this  shortening  was  com- 
pletely overcome;  the  globular  body  above  mentioned  slip- 
ping over  an  irregular  surface,  where  a  distinct  grating 
could  be  recognized.  Abduction  of  the  limb  was  impossible, 
as  the  member  lay  in  its  acquired  position.  As  she  stood, 
there  was  no  deviation  in  the  spinal  column  to  the  right  or 
to  the  left.  I  could  not  find  any  cicatrices,  and  could  get 
no  history  of  suppuration.  The  girl  told  me  that  she  had 
always  walked  lame,  and  furthermore  that  she  hurt  her  hip 
when  four  years  of  age.  Both  father  and  mother  had  been 
dead  several  years,  and  I  had  no  other  one  from  whom  in- 
formation could  be  obtained. 

I  made  out  a  congenital  dislocation  of  the  hip  and  ex- 
plained the  roughened  sensation  on  the  theory  of  an  irregu- 
lar cleft  in  the  upper  rim  of  the  acetabulum.  A  note  was 
sent  Dr.  Sayre  asking  whether  he  meant  by  "  dislocation  of 
long  standing"  a  congenital  dislocation;  and  I  received  a 
reply  in  which  he  stated  "  It  is  not  a  congenital  dislocation, 
as  she  was  perfectly  well  until  she  -was  four  years  old,  when 
she  had  a  fall  down  stairs  out  of  a  girl's  arms,  and  probably 
had  a  diastasis  at  the  neck  of  the  femur,  although  it  may 
possibly  have  been  a  luxation;  but  my  impression  is,  it  was 
a  diastasis." 

The  crepitus,  if  crepitus  it  could  be  called,  on  making 
traction  of  the  limb  seemed  to  me  to  be  the  only  sign 
Which  could  be  regarded  as  one  of  a  diastasis,  and  yet,  in 


DIASTASIS  OF  THE  HEAD   OF  THE  FEMUR.        I$l 

ten  years  time,  crepitation  ought  certainly  to  have  long 
since  disappeared.  Dr.  Sayre  relied  on  the  history  he  got 
from  the  girl  and  I  did  not.  It  will  be  seen  that  it  is  very 
easy  to  err  in  diagnosis.  I  was  not  convinced  by  a  careful 
examination  that  this  was  a  diastasis,  and  even  the  weight 
of  so  great  an  authority  as  that  of  Dr.  Sayre  did  not  con- 
vince me.  I  have  met  with  quite  a  number  of  cases  of 
double  congenital  dislocation  in  which  a  roughening  on 
passive  motion  can  be  easily  recognized.  In  a  recent 
number  of  the  Philadelphia  Medical  Times  is  a  report  of  a 
case  of  epiphysial  separation  by  Dr.  J.  M.  Barton  of  Phila- 
delphia. The  patient  was  a  boy  aged  fifteen  years,  who,  a 
few  days  before  Dr.  B.  saw  him,  had  received  an  injury  to 
his  hip  in  the  following  way:  while  crossing  the  yard  bear- 
ing a  large  bundle,  a  companion  purfied  against  him  so 
that  he  let  the  bundle  fall  to  the  ground  and  rested  his 
hands  upon  it  to  save  himself  from  falling.  While  in  this 
position,  a  second  push  turned  him  over  and  he  came  to 
the  ground  seated,  supporting  his  weight  by  the  hands. 
An  inch  shortening  was  found  on  examination,  and  the  foot 
was  everted,  though  not  as  fully  as  it  is  in  senile  intracapsu- 
lar  fracture.  The  popliteal  space  and  lumbar  spine  were  in 
contact  with  the  bed  at  the  same  time.  The  periarticular 
muscles  were  free  from  spasm,  the  fascia-lata  was  relaxed. 
The  trochanter  was  higher,  more  prominent,  and  nearer 
the  anterior  superior  spinous  process  than  its  fellow. 

Under  ether  the  limb  was  fully  rotated  and  the  trochan? 
ter  described  a  large  arc  of  a  small  circle,  i.e.,  it  rotated  on 
its  own  centre  and  did  not  increase  its  distance  from  the 
median  line  of  the  body.  Traction  reduced  all  deformity 
but  shortening  and  prominence  of  trochanter  returned 
immediately  on  suspending  this  act.  Crepitation  of  an 
unusual  kind  was  felt,  during  these  manipulations,  as  if 
large  surfaces  of  diseased  bone  were  rubbed  together. 

The  patient  was  placed  in  bed  with  extension  and  the 
hip  was  additionally  supported.  At  the  end  of  five  weeks 
there  was  less  than  a  half  inch  of  shortening  and  on  re- 
moving the  extension  the  original  deformity  returned, 
although  under  portable  extension  treatment  for  a  year 
the  shortening  had  increased  to  one  and  a  half  inches. 

Diastasis  is  to  be  differentiated  from: 

1.  An  unusual  form  of  traumatic  dislocation. 

2.  Congenital  dislocation. 

3.  Pathological  separation  in  acute  epiphysitis. 


152  DISEASES  OF  THE   HIP. 

4.  Pathological  separation  in  chronic  articular  ostitis. 

The  treatment  is  simple  and  any  one  recognizing  the 
lesion  early  would  naturally  resort  to  such  means  as  would 
reduce  the  deformity  and  hold  the  fractured  parts  in  appo- 
sition. It  is  very  important  to  fix  the  hip  securely  and 
maintain  the  immovable  dressings  for  at  least  two  months. 
The  parts  will  readily  enough  unite  after  a  fashion,  but 
the  hypersemia  induced  in  neighboring  parts  is  apt,  it 
seems  to  me,  to  set  up  bone  disease,  especially  if  the  child 
be  permitted  to  use  the  limb  while  the  neck  of  the  femur 
is  unprotected. 

In  those  cases  wherein  deformity  has  already  resulted, 
and  the  malposition  of  the  limb  is  such  as  to  occasion  much 
impairment  to  locomotion,  the  treatment  will  be  the  same 
that  is  employed  in  the  correction  of  the  deformity  from 
chronic  bone  disease  of  the  hip. 

Reported  cases  are  indeed  very  scarce  wherein  perfect 
recovery  has  been  obtained.  The  results  seem  to  be  no 
better,  in  fact,  than  those  wheret  he  diaphyso-epiphysial 
lesion  is  an  inflammatory  process. 

The  conclusions,  then,  to  which  my  studies  have  led  me 
are: 

1.  Diastasis  of  the  head  of  the  femur  of  traumatic  pro- 
duction is  an  exceedingly  rare  accident. 

2.  The  diagnosis  at  the  time  of  the  injury  even  is  much 
more  difficult  than  one  would  infer  from  the  signs  given  in 
the  text-books. 

3.  The  diagnosis  years  after  the  occurrence  of  the  de- 
formity depends  altogether  on  the  history,  and  as  histories 
are  so  frequently  biased  by  preconceived  ideas  as  to  the 
nature  of  the  lesion,  this  is  a  very  uncertain  basis  for  an 
opinion. 

4.  Practically  it  makes  no  difference  whether  one  at  this 
advance^  stage  diagnosticates  traumatic   or  pathological 
diastasis,  as  the   treatment  for  the  two  is  identically  the 
same. 

5.  The  results  with  or  without  treatment,  as  far  as  one 
can  judge  from  published  reports  of  cases,  are  the  same  as 
are  obtained  in  chronic  articular  ostitis  of  the  hip. 

The  treatment  must  extend  over  a  longer  period  than  is 
required  for  fractures,  in  view  of  the  nature  of  the  bone  in 
contiguity  to  the  line  of  separation. 


CHAPTER  X. 

I.  PERIOSTITIS  OF  THE  HIP.  —  II.  MALIGNANT  DISEASE  OF 

THE    HlP. 

By  the  terms  periostitis  of  the  hip  I  would  call  attention 
to  a  class  of  cases  coming  frequently  under  observation 
and  distinctly  traceable  to  a  specific  cause,  viz.,  traumatism 
in  some  one  of  its  varied  forms.  It  is  the  periosteum  about 
the  trochanter  which  is  most  frequently  implicated,  but 
sometimes  pelvic  bones  are  involved,  and  we  have  the  same 
lesion  to  contend  with.  The  shaft  of  the  femur,  when  the 
subject  of  periostitis,  does  not  occasion  the  anxiety  that 
the  extremities  of  the  bone  do  when  affected. 

With  acute  diffuse  periostitis  I  am  not  personally  famil- 
iar, and  I  have  no  clinical  experience,  consequently,  to  re- 
cord. To  dissociate  it  from  acute  ostitis  or  acute  osteo- 
myelitis is  hardly  practicable,  however  desirable.  Such 
cases  are  fully  detailed  in  works  on  surgery,  and  come  more 
frequently  under  the  eye  of  the  general  surgeon. 

The  acute  localized  periostitis  from  trauma  and  the  sub- 
acute  and  chronic  forms  occurring  in  the  vicinity  of  joints 
are  not  usually  recognized  in  works  on  surgery,  except  in 
their  relationship  to  the  etiology  or  pathology  of  arthro- 
pathies. 

Periostitis,  secondary  to  an  ostitis,  is  not  an  uncommon 
lesion,  and  then  really  it  is  not  entitled  to  a  distinct  place 
in  the  nomenclature  of  joint  diseases.  To  recognize  the 
primary  localized  periostitis  is  certainly  very  important, 
while  it  matters  little  whether  the  secondary  form  is  recog- 
nized or  not.  In  one,  a  joint  may  be  saved  by  prompt  and 
judicious  surgery  ;  in '  the  other,  the  same  surgery  would 
be  meddlesome.  In  no  department  is  an  early  diagnosis  so 
valuable  as  in  the  disease  of  which  this  chapter  treats. 

Among  the  causes,  a  contusion  is  the  more  frequent. 
Exposure  to  cold,  strains,  and  the  like  often  act  as  direct 
exciting  causes. 

The  symptoms  resemble  closely  those  of  chronic  artic- 


154  DISEASES  OF  THE  HIP. 

ular  ostitis,  and  very  often  the  progress  of  the  case  is 
such  as  to  puzzle  one  in  defining  the  characteristics  of  the 
two.  There  will  be  the  direct  cause,  in  close  proximity  to 
the  date  of  the  swelling,  or,  periosteal  enlargement,  and 
hence  the  necessity  of  becoming  familiar  with  the  touch  of 
all  the  structures  one  can  reach  about  a  joint.  These  pains 
at  times  will  be  most  acute,  depending  largely  upon  the 
severity  of  the  inflammation.  Take,  as  instance,  the  fol- 
lowing case,  which  will  furnish  likewise  some  useful  points 
in  Hiagnosis: 

On  the  2jd  of  October,  1877,  there  hobbled  into  the  Out- 
door Department,  on  crutches,  a  man  aged  twenty-two,  of 
fair  build,  yet  not  well  nourished  ;  and  his  sufferings  were 
so  great,  he  said,  that  he  had  lost  much  flesh  during  the 
past  fortnight.  .His  lameness  was  of  only  four  weeks' 
standing,  and,  in  fact,  none  of  his  symptoms  dated  further 
back.  He  was  a  porter  in  a  mercantile  house,  and  fancied 
that  he  had  strained  himself  while  lifting.  It  seemed  a 
plausible  etiology,  too,  for  his  pain  and  soreness  about  the 
right  hip  began  the  day  after  a  severe  effort  at  lifting  a  case 
of  goods.  Swelling  soon  followed,  and  prior  to  the  date  of 
his  visit  to  the  hospital  a  blister  had  been  applied.  It  was 
difficult  to  secure  an  examination  at  all  satisfactory;  yet 
there  was  found  a  marked  degree  of  infiltration  diffusely 
scattered  throughout  the  gluteal  and  upper  femoral  regions, 
with  tenderness  on  handling,  and  on  attempted  movements 
at  the  hip.  A  diagnosis  was  provisionally  made  of  hip-dis- 
ease in  its  acute  stage,  and  further  vesication  was  ordered. 
October  27th. — Is  able  to  walk  now,  and  feels  very  much 
better.  November  5th. — Walks  with  a  very  slight  limp,  has 
no  pain,  the  infiltration  is  much  less,  and  the  patient  wants 
to  return  to  work.  After  a  week  or  two  he  ceased  coming, 
and  returned  to  his  vocation,  although  the  movements  at 
the  joint  were  not  quite  restored.  He  was  able,  however, 
to  do  only  very  light  work,  and  then  suffered  much  pain 
after  exertion. 

March  zoth,  1878. — Returns  with  a  relapse — i.e.,  swelling, 
pain,  and  tenderness  about  the  trochanter  major  of  two 
weeks' standing.  The  infiltration  this  time  is  phlegmonous 
in  appearance,  and  the  movements  of  the  joints  are  very 
little,  if  at  all  impaired.  He  was  blistered  again,  and  iodide 
of  potassium  was  administered.  This  treatment  was  con- 
tinued with  temporary  benefit,  then  acute  symptoms  re- 
curred, and  finally,  on  May  4th,  an  abscess  on  the  upper  third 


PERIOSTITIS   OF  THE   HIP.  I$5 

of  the  thigh,  outer  aspect,  was  opened.  May  2ist. — A  small 
spicula  of  bone  from  the  shaft  of  the  femur  exfoliated 
through  the  abscess  opening.  After  this  the  discharge 
ceased,  and  the  opening  soon  closed.  June  5th. — Discharged 
cured :  no  lameness  ;  no  pain  ;  no  infiltration.  Nothing 
further  occurred  until  January  22, 1879,  when  he  returned 
with  a  swelling -and  tenderness  over  the  spine  of  the  tibia 
on  the  same  side,  of  ten  days'  standing.  The  circumfer- 
ence is  one  inch  greater  than  that  of  the  fellow  limb  at  the 
corresponding  point.  Periostitis  of  the  tibia  is  diagnosti- 
cated, and  iodide  of  potassium,  gr.  x.,  t.  i.  d.,  ordered.  An 
incision  was  made  to  the  bone  on  the  i3thof  February,  and 
more  blood  than  pus  evacuated.  After  a  few  days  there 
was  an  increased  flow  of  pus,  and  a  few  days  later  the 
wound  closed.  He  was  discharged  cured  on  the  2ist  of 
February.  Seen  December  i3th  as  a  conductor  on  the 
Fourth  Avenue  Railroad,  and  declares  that  he  has  not  suf- 
fered the  slightest  inconvenience  since  last  spring.  Con- 
siders himself  perfectly  restored. 

Within  the  past  year  I  have  seen  the  subject  of  the  above 
history,  and  he  has  never  had  any  return  of  symptoms. 

In  some  instances,  especially  in  young  children,  the  case 
becomes  exceedingly  chronic,  and  the  abscesses  open  and 
discharge  to  close  again,  year  in  and  year  out.  A  bright  girl, 
eleven  years  of  age,  was  admitted  to  hospital  in  the  spring 
of  1881.  She  seemed  to  be  in  excellent  health,  but  was 
quite  lame,  and  presented  a  marked  degree  of  deformity  at 
the  right  hip.  The  movements  were  limited  to  a  small  arc, 
although  the  joint-surfaces  were  smooth.  Below,  and  in 
front  of  the  trochanter,  a  sinus  existed,  while  on  the  outer 
surface  of  the  thigh  were  four  cicatrices.  There  was  an 
inch  and  a  half  shortening.  A  little  over  two  years  before 
her  admission  she  had  fallen,  striking  the  hip  ;  pains  about 
the  thigh  and  knee  speedily  followed,  and  on  the  thigh  a 
periosteal(?)  swelling  appeared.  This  developed  into  an  ab- 
scess and  was  soon  opened.  A  high  shoe  was  worn  on  the 
foot  of  the  sound  limb — the  child  going  about  on  crutches. 
Extension  by  weight  and  pulley  was  not  tolerated  well,  and 
she  seemed  to  derive  the  greatest  relief  from  the  crutches 
and  high  shoe.  For  four  years  these  sinuses  would  open 
and  close,  giving  rise  to  deformity  which  would  subside  as 
the  inflammation  subsided.  Finally,  she  recovered  with 
an  inch  shortening,  with  scarcely  an  appreciable  lameness, 
and  with  perfect  motion  at  the  joint. 


I§6  DISEASES   OF  THE  HIP. 

The  fact  that  many  of  these  patients  suffer  from  the 
most  intense  pain  is  due  to  the  locality  of  the  inflamma- 
tory process;  The  formation  of  pus  sacs  in  contiguity 
with  nerve-bundles  of  course  induces  pain.  I  have  seen 
instances  where  the  periosteum  covering  the  pubis  was  in- 
flamed and  the  symptoms  were  referable  to  this  region. 
The  iliac-fossa  and  the  crest  are  occasionally  injured,  and 
the  nates  are  altered,  the  inguinal  glands  are  enlarged  as 
the  lesion  extends,  and  the  joint  movements  are  more  or 
less  restricted.  A  boy,  aged  four  and  a  half  years,  came 
under  my  observation  October  5th,  of  last  year,  with  a  hard- 
ish  swelling  under  the  gluteal  muscles  in  close  proximity 
to  the  sacro-iliac  junction,  right  side.  He  fell  in  July, 
striking  against  the  rocker  of  a  chair.  The  signs  came  on 
very  slowly,  and  the  thickening  of  the  periosteum  had  only 
recently  been  observed.  No  sacro-iliac  tenderness,  and  no 
hip-joint  tenderness  could  be  discovered.  The  subsequent 
progress  of  the  case  fully  confirmed  the  diagnosis  made, 
the  neighboring  joints  remaining  free. 

The  diagnosis  is  made  on  the  history  and  on  the  presence 
of  a  periosteal  thickening,  if  the  case  comes  under  observa- 
tion early,  and  if  later,  then  the  extent  of  the  sinuses  and 
the  absence  of  joint  lesion.  These  are  the  chief  points  on 
which  one  can  base  an  opinion,  but  all  surgeons  know  that 
in  very  few  instances  can  they  get  sufficient  data  for  a 
sharply  defined  anatomical  diagnosis.  Between  an  ostitis 
and  a  periostitis  there  exist  many  symptoms  in  common. 
I  remember  a  boy,  aged  ten  years,  who  was  admitted  to  hos- 
pital January  26,  1876,  and  in  the  absence  of  a  history  I 
made  a  diagnosis  of  "hip-disease "  second  stage,  employ- 
ing the  term  to  indicate  an  articular  ostitis.  I  found  him 
with  the  limb  advanced  and  foot  everted,  walking  with  a 
slight  limp.  The  natis  was  much  broadened,  fold  lowered, 
and  while  I  could  elicit  no  joint  tenderness,  the  limit  to  ex- 
tension was  150°,  to  flexion  130°,  and  there  was  a  little 
atrophy.  Under  a  liniment,  and  hospital  regime  all  symp- 
toms and  signs  disappeared  by  the  following  March.  The 
functions  of  the  joint  being  found  normal,  he  was  dis- 
charged cured,  to  be  readmitted,  however,  on  the  nth  of  the 
following  August.  I  found  then  a  circumscribed  indura- 
tion on  the  inner  side  of  the  thigh,  without  any  fluctuation 
discoverable.  The  skin  was  pinkish  in  hue  and  deprived  of 
its  epidermis.  No  muscular  spasm  of  a  reflex  nature  exis- 
ted about  the  hip,  and -no  other  evidence  of  a  joint  disease 


J>ERiOSTITiS  OF  tHE  Hit*; 

Could  be  found.  My  diagnosis  was  at  this  time  a  simple 
cellulitis.  This  area  broke  down  into  ulcers,  and  sinuses 
followed,  which  discharged  more  or  less  during  the  next 
two  or  three  months.  In  December  these  closed,  while  a 
similar  condition  of  degeneration  presented  itself  on  the 
outer  side  of  the  thigh;  Repeated  exacerbations  with  a 
mild  grade  of  constitutional  symptoms  supervened,  and  in 
March  the  inner  side  of  the  thigh,  in  the  old  locality,  began 
to  behave  badly  again.  Abcess  formed  here,  and  in  May, 
a  spicula  of  bone  was  exfoliated.  This  completed  the  cure, 
and  I  had  myself  to  censure  for  taking  fifteen  months  to 
recognize  the  true  nature  of  the  disease.  But  for  the  clini- 
cal features  in  the  case  it  would  be  humiliating  to  place  it 
on  record.  It  teaches  the  value  of  the  probe,  if  that 
lesson  were  necessary  in  this  enlightened  age  of  surgical 
science.  I  have  seen  far  more  abuse  from  neglect  of  this 
simple  aid  to  diagnosis  than  damage  done  to  healthy  or 
diseased  parts  by  its  employment  in  the  hands  of  the 
most  reckless.  I  am  aware  that  some  honest  surgeons  of 
large  experience  condemn  its  use  because  of  supposed  in- 
juries done.  Had  I  resorted  to  it  in  this  case  I  should  surely 
have  been  spared  the  error  of  diagnosticating  a  cellulitis  on 
the  boy's  readmission.  Remembering  the  influence  of  cold 
as  a  cause  of  periosteal  inflammations,  I  had  no  difficulty 
in  forming  a  correct  opinion  in  the  following  case.  This 
one  is  so  interesting  from  a  therapeutical  point  of  view 
that  I  find  it  very  serviceable  at  this  juncture  because  I  can 
illustrate  what  further  remarks  I  have  to  make  on  diagno- 
sis, passing  at  the  same  time  to  the  treatment. 

A  lad,  aged  fifteen,  was  referred  to  me  for  "hip  disease" 
by  a  medical  friend,  who  had  made  only  a  cursory  examin- 
ation, during  the  latter  part  of  1881.  Two  months  before 
his  appearance  at  the  hospital  he  had  taken  a  surf  bath  one 
cool  day  in  August,  and  the  next  day  without  any  chill  pre- 
ceding he  had  a  slight  febrile  exacerbation  attended  with 
headache.  The  next  ten  days  found  him  confined  to  bed, 
complaining  much  of  pain  in  the  upper  portion  of  the  left 
thigh  and  in  the  hip.  There  was  no  pain  referable  to  the 
knee  or  its  coverings.  In  the  upper  third  of  the  thigh  was 
considerable  tenderness.  At  the  end  of  the  ten  days  on 
getting  out  of  bed  he  was  able  to  walk  only  with  the  aid  of 
two  canes.  The  patient  walked  with  a  cane  into  my  ex- 
amining room;  he  was  anaemic;  the  limb  was  flexed  at 
the  hip  and  rotated  inward;  the  deformity  was  not  marked, 


158  DISEASES  OF  THE   HIP. 

yet  suggestive.  I  could  not  discover  any  joint  tenderness- 
but  on  measurement  found  the  circumference  of  the  thigh 
in  its  upper  third  one  and  a  half  inches  greater  than  that 
of  its  fellow;  the  whole  limb  was  apparently  an  inch  longer 
than  the  right;  really  there  was  no  difference.  The  indu- 
ration was  confined  to  the  outer  aspect  of  the  limb,  and  to 
my  touch  seemed  unmistakably  periosteal.  There  was  no 
fluctuation,  but  there  was  extra  heat  and  tenderness.  I 
did  not  thoroughly  test  the  joint  movements,  but  found  the 
articular  surfaces  quite  smooth  on  moving  the  limb  over 
small  arcs.  The  diagnosis  was  made  unhesitatingly  of 
periostitis  of  the  shaft  in  its  upper  portion,  and  I  ordered 
a  high  shoe  for  the  sound  limb  and  a  pair  of  crutches  to 
correspond.  An  iodine  liniment,  cotton  batting,  cod-liver 
oil,  and  a  tonic  completed  the  order. 

This  was  followed  faithfully,  and  the  boy  did  well  for  a 
month,  in  so  far  as  freedom  from  pain  and  comfort  were  con- 
cerned. Then  the  area  of  induration  became  more  circum- 
scribed, and  while  I  could  get  no  fluctuation  I  felt  quite 
sure  that  the  disease  was  not  receding.  Hot  fomentations 
were  substituted  for  the  cotton-batting,  and  when  I  saw  the 
patient  again — a  week  later — a  spontaneous  opening  had 
occurred,  and  a  sero-purulent  discharge  issued  therefrom. 
Carbolic  acid,  in  weak  solution,  was  employed  as  an  injec- 
tion, and  at  his  next  visit  he  brought  me  two  spiculae  of 
bone,  less  than  a  half-inch  in  length,  which  he  had  removed 
himself  from  the  sinus  the  day  before.  By  exploring  freely 
I  could  not  detect  any  more.  The  sinus  was  kept  open, 
however,  and  within  the  next  fortnight  two  more  spiculae 
were  exfoliated. 

In  April  he  fell  down  a  half-dozen  steps,  striking  on  the 
trochanter,  and  the  sinus  bled  a  little.  A  week's  rest  and  a 
sojourn  in  the  country  proved  highly  beneficial.  In  October 
a  good-sized  shell  of  bone  was  removed  from  the  sinus,  and 
this  proved  to  be  the  last  exfoliations  of  any  significance. 
The  sinuses  closed,  the  joint  movements  became  more  free, 
and  the  crutches  were  discontinued.  He  had  no  lameness, 
no  shortening  of  the  limb,  and  he  was  regarded  as  cured, 
until  six  months  later,  when  the  sac  filled  again,  and  quite 
an  insignificant  piece  of  bone  was  thrown  off.  He  soon  re- 
covered, and  has  been  on  the  convalescent  list  now  for  a 
year,  with  instructions  to  call  only  on  the  recurrence  of  any 
symptoms. 

There   came   into  my  examining- room  one  morning   in 


PERIOSTITIS   OF  THE  HIP.  1 59 

December,  1881,  a  boy,  aged  eight,  whose  case  I  looked  upon 
as  an  excellent  result  from  an  old  periostitis,  with  necrosis 
and  exfoliation  of  bone.  He  had  no  atrophy  of  the  thigh, 
only  a  half-inch  of  the  calf,  and  no  shortening  of  the  limb. 
The  joint-surfaces  were  smooth,  and  the  functions  normal. 
An  old  cicatrix  existed  about  the  trochanter,  and  he  reported 
that  spiculse  of  bone  had  been  exfoliated  through  an  abscess 
in  this  locality. 

I  learned  that  he  had  been  a  patient  of  Dr.  Schoenem'an's, 
of  this  city,  and  at  my  request  the  Doctor  very  kindly  fur- 
nished me  a  copy  of  his  notes  of  the  case,  an  abstract  of 
which  I  here  present.  He  had  first  seen  the  boy  in  February, 
1881,  and  had  obtained  a  strumous  history.  The  boy  had 
a  fever  of  some  kind  in  the  November  preceding,  and  on 
convalescing,  a  few  weeks  later,  complained  of  pain  in  the 
right  hip,  occasionally  in  the  knee  of  the  same  side.  There 
was  some  fulness  around  the  hip-joint,  and  the  only  point  of 
tenderness  was  below  and  anterior  to  the  great  trochanter. 
Movement  in  every  direction  was  easy  and  normal  in  extent, 
though  the  boy  complained  a  little  when  ab-  and  adduction 
were  carried  to  extremes.  The  treatment  to  be  employed 
was  a  long  splint;  but  nothing  was  done  prior  to  July  pth, 
when  it  was  recorded  that  he  was  not  able  to  walk,  and  suf- 
fered from  pain  in  hip,  thigh  and  knee.  The  gluteal  region 
presented  much  fulness,  the  fold  was  obliterated,  and  motion 
was  limited  and  painful  in  every  direction.  On  the  outer 
side  of  the  thigh,  at  its  middle  third,  was  a  fluctuating 
tumor.  The  splint  had  been  applied  on  July  14th,  but  very 
little  extension  was  made.  Warm  fomentations  were  em- 
ployed. The  splint  soon  gave  relief,  and  on  July  28th  the 
abscess  opened  spontaneously.  A  probe  reached  bare  bone 
over  the  trochanter.  Carbolic  acid  injections  of  the  usual 
stfength  were  ordered  as  a  wash  three  times  a  day.  A  small 
piece  of  bone  (size  of  a  pea)  was  exfoliated  on  August  6th. 
The  deformity  of  the  limb  had  by  this  time  disappeared. 
Later,  abscesses  forming  about  the  sinus  were  opened  and 
thorougly  cleansed  with  carbolic  acid  solution.  The  dis- 
charge continued,  more  and  less  profusely,  until  November, 
when  the  sinuses  closed.  The  splint  was  then  removed, 
and  the  boy  began  to  walk  without  assistance. 

The  case  which  I  had  under  my  own  observation  had 
about  the  same  history,  progress,  etc.,  as  Dr.  Schoeneman's 
had.  The  one  was  treated  by  the  method  known  as  that  of 
«'  physiological  rest,"  the  other  by  the  long  splint.  Both 


160  DISEASES  OF  THE  HIP. 

made  excellent  recoveries,  and  the  time  required  was  about 
the  same.  The  principles,  then,  which  these  cases  teach  are: 
the  maintainance  of  good  position  of  the  fimb,  a  certain 
degree  of  rest  to  the  parts,  and  general  constitutional 
measures. 

Mr;  C.  Madnamara,  of  the  Westminster  Hospital,  Lon- 
don, thinks  very  highly  of  the  extract  of  belladonna,  freely 
applied,  over  the  inflamed  area,  in  conjunction  with  perfect 
rest  to  the  parts,  and  his  reported  results  are  most  excellent. 
He  introduces  a  grooved  needle  when  pus  is  suspected, 
presses  the  fluid  contents  out  along  the  needle,  and  then 
places  a  firm  compress  over  the  parts.  In  view  of  one  or 
two  cases  that  have  gone  on  to  fatal  results,  I  am  convinced 
that  early  incisions,  or  needling,  such  as  Mr.  Macnamara 
practices,  should  command  more  attention.  I  have  in  mind 
now  a  case  seen  many  years  ago,  where  a  sharply-defined 
diagnosis  was  made  of  subacute  periostitis  about  the 
trochanter,  where  the  progress  of  the  case  fully  confirmed 
the  diagnosis  made,  where  constitutional  treatment  was 
alone  employed,  where  abscess  after  abscess  gradually  in- 
vaded the  joint,  where  amyloid  degeneration  super- 
vened, and  where  death  by  exhaustion  has  recently  oc- 
curred. 

In  chronic  tibial  periostitis,  as  well  as  in  the  acute  form 
I  have  had,  as  have  others,  most  gratifying  results  from  free 
incisions  down  through  the  inflamed  periosteum  to  the  bone, 
even  when  pus  was  not  even  expected.  Such  treatment  in 
the  neighborhood  of  the  hip  must  become  popular  when  we 
begin  to  distinguish  with  tolerable  accuracy  between  the 
various  diseases  prevalent  about  this  articulation.  The  pre- 
vention of  necrosis  and  ostitis  by  contiguity  is  especially  to- 
be  considered,  and  the  protection  to  the  joint  structures  aids 
materially  in  limiting  the  imflammatory  process. 

There  are  other  remedies  which  are  sometimes  resorted 
to  with  good  result,  such  as  blistering  and  other  means  of 
counter-irritation.  Fomentations  likewise  are  called  for  in 
the  relief  of  pain  when  the  knife  is  not  employed. 

As  regards  medication  the  iodides  are  in  good  repute, 
but  I  doubt  very  much  their  great  value  unless  a  syphilitic 
element  prevail.  I  should  rather  rely  on  tonics,  cod-liver 
oil  and  a  good  hygiene.  The  last  we  cannot  always  com- 
mand. Indeed,  the  art  of  medicine  is  truly  an  art  when  it 
works  good  against  all  such  obstacles. 

The  prognosis  is  good  if  a  correct  diagnosis  can  be  made 


MALIGNANT  DISEASE  OF  THE  HIP.  l6l 

and  if  treatment  can  be  carried  out  on  strict  surgical 
principles.  A  case  of  trochanteric  periostistis,  or  iliac 
periostitis  if  allowed  to  pursue  its  own  course,  will  do  one 
of  two  things.  If  mild  in  type  resolution  will  in  all  prob- 
ability take  place  within  a  few  weeks;  if  it  be  of  a  more 
severe  type  and  occur  in  an  individual  of  cachectic  habit, 
the  march  will  be  slow,  yet  undeviating,  to  a  bony  joint 
disease,  the  final  outcome  of  which  no  man  can  predict. 
That  many  cases  of  so-called  hip-joint  disease  originate  in 
this  way  I  have  long  since  been  convinced.  Dangerous 
expectancy  it  is  to  overlook  these  periosteal  contusions. 
In  infants  the  enforced  rest  soon  brings  about  a  cure  if  in- 
herited syphilis  be  not  an  etiological  factor. 

The  prognosis  of  acute  diffuse  periostitis  involving  the 
shaft  of  the  bone  is  -grave  enough,  though  prompt  thera- 
peutics have  deprived  this  of  much  of  its  terror  since  the 
memoirs  of  Chassaignac  in  1854,  and  the  paper  of  Dr. 
Demme,  of  Berne,  in  1862.  The  incisions  that  they  recom- 
mended, and  which  were  followed  by  such  disastrous 
results,  made  now  under  antiseptic  precautions,  would  seem 
to  overcome  the  objections  urged  then  against  the  pro- 
cedure. Their  cases,  however,  were  those  of  osteo-myelitis, 
in  which,  of  course,  a  suppurative  periostitis  existed. 

II. 

MALIGNANT  DISEASE  OF  THE  HIP. 

Intimately  associated  with  periostitis  is  a  class  of  diseases 
whose  beginning  is  obscure,  whose  termination  is  fatal,  and 
whose  early  diagnosis  is  next  to  impossible.  The  most 
prevalent  of  the  maglignant  diseases  are  the  sarcomas,  and 
Bilroth  believes  that  their  subdivisions,  made  according  to 
histological  peculiarities,  are  of  no  great  value  during  life. 
Dr.  S.  W.  Gross  believes  differently,  and  in  a  paper  showing 
careful  elaboration,  makes  a  very  interesting  study  of  sar- 
coma of  the  long  bones,  based  upon  an  analysis  of  one 
hundred  and  sixty^five  cases.  He  found  that  the  most 
frequent  were  sarcoma.  Osteomas,  chondromas,  osteoid 
chondromas,  fibromas  and  myxomas  prevail  next  in  fre- 
quency in  the  order  named.  His  paper  has  been  published 
in  the  American  Journal  of  the  Medical  Sciences  for  July 
and  October,  1879. 

Tumors  of  the  long  bones  begin  either  in  the  periosteum 


162  DISEASES  OF  THE  HIP. 

or  in  the  medulla.  Thus  we  have  central  sarcoma  and 
periosteal  sarcoma.  The  term  osteo-sarcoma  is  an  unfor- 
tunate one,  as  Dr.  Gross  has  pointed  out.  It  means  one 
of  two  things  :  either  a  sarcoma  in  or  on  a  bone,  or  a  sar- 
coma in  the  soft  parts  containing  osseous  matter.  Wilks 
and  other  English  writers  have  designated  the  periosteal 
osteoids  osteo-sarcomas,  and  some  German  pathologists 
apply  this  name  to  the  myeloid  tumors  only.  These  are 
the  giant-celled  tumors,  and  are  always  central.  The  cen- 
tral tumors  are  as  a  rule  enclosed  in  a  bony  capsule,  i.e.,  the 
major  portion  is  bony,  while  other  portions  may  be  mem- 
branous. The  peripheral  or  periosteal  sarcomas  are 
covered  by  the  outer  fibrous  layer  of  the  periosteum,  and  if 
this  tissue  participates  in  the  cell  proliferation  the  capsule 
is  composed  of  connective  tissue.  Osseous  tissue  is  never 
found  in  the  investing  membrane. 

The  periosteal  are  the  malignant  tumors  one  finds  most 
frequently  in  the  neighborhood  of  the  hip,  and  are  the 
growths  that  present  for  differential  diagnosis. 

In  Dr.  Gross's  tables,  including  all  the  bones  involved, 
the  femur  was  the  seat  of  disease  in  sixty-seven  cases  out 
of  the  hundred  and  sixty-five.  The  central  giant-celled 
tumors  are  not  met  with  during  childhood,  so  that  in  differ- 
entiating neoplasia  in  children  we  can  eliminate  this  class. 
Even  in  adult  life  the  upper  epiphysis  is  seldom  implicated. 
Thus,  in  seventy  cases  of  the  giant-celled  variety  the  upper 
epiphysis  was  the  seat  of  disease  in  only  two  instances, 
while  the  lower  epiphysis  was  affected  seventeen  times. 

The  round-celled  sarcomas,  which  are  periosteal,  are  the 
tumors  which  are  the  more  apt  to  present  in  early  life,  and 
even  these  were  found  to  occur  not  earlier  than  the  seventh 
year  in  the  tables  above  mentioned.  Naturally,  in  the  large 
clinical  field  to  which  I  have  had  access  I  should  find  this 
disease  in  early  life,  if  at  all,  and  in  the  many  hundred 
cases  of  disease  in  and  about  the  hip,  I  have  notes  of  only 
three  or  four.  I  seldom  meet  with  cases  where  even  the 
diagnosis  seems  at  all  probable. 

The  clinical  history  is  very  important,  and  I  gladly  place 
on  record  the  following,  which  will  serve  me  as  a  text  for 
remarks  on  pathology,  diagnosis  and  therapeutics. 

On  the  zoth  of  July,  1881,  I  saw  a  boy  aged  three  years, 
and  diagnosticated  chronic  periostitis  of  the  middle  third 
of  the  right  femur  on  the  strength  of  pains  in  this  vicinity 
a.nd  a  slight  bony  enlargement,  which  was  quite  smooth. 


.  MALIGNANT  DISEASE  OF  THE  HIP.  163 

He  had  been  complaining  of  vague  pains  in  the  limb  for 
several  months,  and  had  not  rested  well  at  night.  There 
was  no  lameness  and  no  impairment  of  joint  function. 

He  was  in  fine  physical  condition  and  the  fulness  had 
been  observed  only  a  few  days.  The  swelling,  or,  enlarge- 
ment completely  encircled  the  bone,  yet  there  was  no 
tenderness  whatever.  I  could  not  learn  any  cause  either 
predisposing  or  exciting.  The  symptoms  yielded  to  lotions, 
etc.,  and  it  was  not  until  September  that  my  fears  were 
aroused.  I  found  then  that  the  size  of  the  limb  had  been 
rapidly  increasing,  and  on  measurement  the  thigh  in  its 
upper  third  was  two  inches  larger  than  its  fellow,  in  its 
middle  third  it  was  three  and  a  quarter  inches  larger,  and 
in  its  lower  third  one  inch.  In  one  or  two  points  I  got 
deep  fluctuation,  yet  there  was  a  bony  hardness  generally 
over  the  mass,  and  the  boy  was  suffering  much  at  night. 
The  superficial  veins  were  growing  prominent.  I  now  gave 
up  the  idea  of  a  periostitis  and  felt  quite  sure  that  the 
growth  was  malignant.  The  shape  was  ovoid,  the  skin 
was  unaffected  and  the  tenderness  was  not  marked.  Dr. 
Weir  saw  the  case  in  consultation,  agreed  with  me  that  it 
was  one  of  sarcoma  of  the  femur  and  advised  amputation. 
Dr.  Ripley,  after  a  microscopical  examination  of  a  bloody 
fluid  removed  from  one  of  these  fluctuating  areas  arrived, 
at  the  same  diagnosis.  He  agreed  with  Dr.  Frank  Hamil- 
ton, who  made  the  same  diagnosis,  in  advising  against 
operation.  By  the  latter  part  of  September  there  were 
four  inches  difference  in  the  size  of  the  two  limbs  and  yet  the 
boy  was  walking  with  very  little  inconvenience,  and  had  not 
lost  flesh. 

The  parents  would  not  consent  to  any  operative  procedure 
and  I  had  the  melancholy  privilege  of  following  the  case 
to  the  end.  Through  the  month  of  October  the  increase  in 
size  went  on  without  marked  deterioration  of  health.  The 
growth  extended  from  condyle  to  condyle  by  the  latter 
part  of  November  and  the  veins  had  become  large  and 
tortuous.  Rest  was  obtained  only  under  the  influence  of 
morphia.  The  circumference  was  seventeen  and  a  half 
inches  against  eight  and  a  half  for  the  other  limb.  The 
lymphatic  glands  were  not  involved,  the  skin  was  normal 
and  the  joints  of  the  hip  and  knee  were  smooth  and  as 
yet  unaffected. 

In  December  emaciation  was  first  apparent  and  he  was 
unable  longer  to  go  about.  Though  January  and  February 


164  DISEASES  OF  THE  HIP. 

he  dragged  along,  eking  out  a  suffering  existence,  the  limb 
looking  like  a  vast  appendage  to  a  small  body.  In  the 
early  part  of  March  a  superficial  vein  on  the  anterior  sur- 
face of  the  tumor  ruptured  and  the  boy  lost  considerable 
haemorrhage  before  assistance  was  rendered.  The  appear- 
ance of  the  parts  on  the  ist  of  April  is  well  represented  by 
the  accompanying  sketch  made  for  me  by  Dr.  Crook. 

The  skin  did  not  slough,  and  there  was  no  haemorrhage 
of  any  significance,  but  the  boy  became  oedematous  and 
gradually  sank  April  4th,  dying  by  exhaustion.  Per- 
mission was  given  to  remove  the  tumor,  and  with 
the  assistance  of  Dr.  G.  W.  Ryan  I  made  a  dissection  of  the 
parts  involved.  The  thigh  was  disarticulated  at  knee  and 
hip,  the  former  joint  with  the  superficial  parts  of  the  lower 
epiphysis  being  found  absolutely  normal.  The  latter  joint 
was  filled  with  a  gelatinous-looking  fluid,  although  the 
acetabulum  was  smooth  and  the  head  of  the  femur  seemed 


FIG.  io.— ROUND-CELLED  PERIOSTEAL  SARCOMA. 

normal.  The  greater  portion  of  the  thigh,  inclusive  of 
muscles  and  bone,  was  replaced  by  the  neoplasm.  The 
mass,  deprived  of  the  integument,  weighed  ten  pounds, 
and  the  jelly-like  appearance  on  longitudinal  section,  of 
blanc-mange  ;  no  muscular  tissue  could  be  found.  Here 
and  there  were  a  few  cysts  of  varying  size.  The  periosteum 
could  be  distinctly  traced  out  in  the  mass,  it  being  separa- 
ted from  the  bone  in  a  crescentic  manner,  the  greatest  dis- 
tance of  separation  being  one  inch. 

Dr.  William  H.  Welch  made  a  microscopic  examination 
and  reported  that  "the  tumor  is  composed  of  a  mass  of 
cells  with  little  intercellular  substance,  and  is  quite  rich  in 
blood-vessels.  The  cells  are  for  the  most  part  small  round 


MALIGNANT  DISEASE   OF  THE  HIP.  165 

cells,  but  there  are  some  larger  round,  as  well  as  irregular 
cells.  Here  and  there  are  a  few  giant-cells.  There  is  no 
alveolar  or  other  regular  arrangement  of  the  elements.  To 
the  naked  eye  it  is  clear  that  the  tumor  originated  in  the 
periosteum.  Diagnosis  :  Round-celled  sarcoma  of  the  perios- 
teum." The  earliest  period  of  life  at  which  the  disease 
showed  itself  in  the  eleven  cases  analysed  by  Dr.  Gross  was 
seven  years.  In  the  case  I  have  just  reported  the  first 
symptoms  appeared  before  the  boy  was  three  years  of  age. 
I  saw  a  case  last  fall  in  a  boy  aged  four  and  a  half  years 
wherein  the  disease  had  lasted  for  nearly  three  years.  In 
this  boy  the  pelvic  bones  were  involved  and  the  tumor 
filled  the  whole  of  the  external  iliac  fossa,  including  the 
hip.  The  inguinal  glands  were  much  enlarged,  but  whe- 
ther from  irritation  or  disease  I  could  not  tell.  The  first 
symptoms  were  noticed  when  he  began  to  walk.  The  case 
was  seen  also  by  Dr.  Yale,  who  felt  no  hesitancy  in  pro- 
nouncing it  a  sarcoma.  This  was  much  slower  in  its  growth 
than  the  other  case. 

Pain,  in  the  case  I  have  detailed  at  length,  was  a  most 
persistent  feature,  especially  after  the  tumor  reached  such 
dimension.  There  was  never  any  pulsation,  and  fracture 
did  not  occur.  Dr.  L.  E.  Holt  related  to  me,  at  the  time  I 
was  so  much  interested  in  the  above  cases,  the  history  of 
another  that  had  come  under  his  observation,  and  it  was  as 
follows:  In  the  summer  of  1881,  he  saw,  with  Dr.  Denning, 
of  Webster,  New  York,  a  girl  nine  and  a  half  years  of  age, 
who  had  for  a  long  time  been  suffering  from  what  was  re- 
garded as  chronic  hip-joint  disease.  The  family  history 
was  good,  and  the  patient's  own  health  had  been  good. 
When  five  years  of  age  she  had  for  several  days  sharp  neu- 
ralgic pains  in  the  right  knee  without  preceding  lameness. 
The  pains  passed  away,  without  treatment,  and  a  year  later 
returned  with  greater  severity,  lasting  several  weeks,  and 
during  this  time  she  walked  very  lame.  She  soon  got  re- 
lief spontaneously,  but  for  a  few  months  only,  as  the  pain, 
lameness  and  deformity  returned  and  continued  with  very 
little  remission.  The  girl  attended  school  quite  regularly, 
until  nine  years  of  age.  About  this  time  the  parts  took  an 
-increased  enlargement  and  pain  at  times  became  excruciat- 
ing. Her  screams  were  sometimes  heard  a  quarter  of  a  mile 
distant.  For  three  months  prior  to  the  date  of  Dr.  Holt's 
examination  opiates  were  used  daily.  Profuse  night-sweats, 
without  any  chills,  had  of  late  appeared.  He  found  the 


166  DISEASES  OF  THE  HIP. 

patient  thin,  but  not  emaciated;  a  pulse  of  150,  and  a  tem- 
perature of  102.5°  The  right  thigh  was  flexed  at  90°  and 
adducted.  The  pelvis  moved  with  every  attempt  at  passive 
motion  of  the  limb.  An  immense  tumor  occupied  the  region 
of  the  hip,  extending  vertically  from  the  crest  of  the  ilium 
to  the  middle  third  of  the  thigh,  and  transversely  from  the 
gluteal  cleft  to  the  labium  majus.  In  the  groin  it  extended 
above  Poupart's  ligament,  but  followed  its  direction.  In 
this  locality  the  surface  was  a  little  irregular,  but  everywhere 
else  it  was  smooth  and  uniform.  The  skin  was  tense  and 
glistening  and  over  the  nates  a  little  discolored;  the  super- 
ficial veins  were  prominent. 

There  was  no  tenderness  on  palpation,  but  there  was  a 
sense  of  deep  fluctuation.  Moderate  concussion  of  the 
joint  surfaces  elicited  no  tenderness,  but  any  efforts  at  pas- 
sive motion  excited  great  pain,  especially  if  rotation  were  at- 
tempted. The  circumference  of  the  limb  over  groin  and 
trochanter  was  twenty  inches  against  eleven  for  the  opposite 
side.  From  the  anterior  superior  spinous  process  to  the 
gluteal  cleft  the  measurement  was  eleven  and  a  half  inches, 
that  between  same  points  on  left  side  six  and  a  half.  There 
was  apparently  no  shortening  of  the  limb.  The  rapid  en- 
largement, the  loss  of  flesh,  and  the  hectic  with  the  ap- 
pearance of  the  skin  led  the  Doctor  to  believe  that  he  had 
to  deal  with  a  deep-seated  collection  of  pus.  The  patient 
was  accordingly  anaesthetized  and  a  four-inch  aspirator 
needle  was  introduced  to  the  full  length  in  several  direc- 
tions, and  in  every  instance  only  a  few  drops  of  blood  were 
obtained.  It  was  very  evident  that  no  abscess  was 
present. 

While  the  girl  was  under  ether  a  little  motion  was  ob- 
tained over  an  arc  of  about  twenty  degrees.  She  grew 
steadily  worse  and  in  a  few  months  died  of  exhaustion. 
An  autopsy  could  not  be  secured. 

The  character  of  these  tumors  in  general  appearance  de- 
ceives many.  When  fluctuation  is  discovered  no  ill  results 
can  follow  the  introduction  of  a  hypodermic  needle.  The 
appearance  of  blood  when  one  explores  for  pus  is  always 
of  the  gravest  significance. 

Little  need  be  said  upon  the  subject  of  treatment.  Opin- 
ions are  about  evenly  divided  on  the  question  of  operation 
or  palliation. 

Dr.  Gross  collected  thirteen  cases  of  periosteal  round- 
celled  sarcoma,  and  all  were  subjected  to  operation  save  one. 


MALIGNANT  DISEASE  OF  THE  HIP.  167 

This  one  he  could  not  compare  with  the  remaining  twelve 
because  of  the  incompleteness  of  the  history.  Of  the  twelve 
that  he  analyzed  ten  underwent  amputation  and  two  ex- 
cision. The  two  that  were  excised  involved  the  shoulder 
joint  and  in  both  cases  the  disease  returned.  There  were 
four  of  the  twelve  that  did  not  have  a  perfect  history,  so 
that  in  estimating  the  prognosis  as  regards  duration  of  life 
he  was  confined  to  eight.  The  time  from  the  first  observa- 
tion of  the  disease  to  the  close  of  life  varied  from  two 
months  and  a  half  to  five  years  and  one  third.  The  average 
was  eighteen  months.  "  Of  the  eight  cases  in  two  death 
was  due  directly  to  surgical  measures;  one  recovered,  but 
died  from  metastatic  deposits  at  the  expiration  of  thirty- 
two  months;  three  recovered,  but  died  subsequently  from 
supposed  systemic  infection  respectively  at  seven,  eight,  and 
nine  months  ;  one  was  alive  with  local  recurrence  at  the 
end  of  three  weeks;  and  one  remained  well  for  forty  months." 
In  the  case  I  have  reported  on  page  162,  it  was  the 
mother's  regret  that  she  had  not  consented  to  the  operation. 
My  own  conviction,  from  my  knowledge  of  the  life  the 
little  sufferer  led,  is  that  operation  should  be  done  even  if 
there  is  not  a  single  chance  of  recovery.  We  know,  how- 
ever, that  life  can  be  prolonged,  and  we  know,  furthermore, 
that  suffering  can  be  ameliorated  by  such  procedure.  I 
saw  that  child  from  time  to  time,  and  saw  him  in  pain  and  in 
distress;  saw  that  ponderous  mass  threatening  haemorrhage 
and  sudden  destruction  to  life  ;  saw  the  emaciated  body 
fading  into  insignificance  beside  the  tumor,  and  saw  the 
mother  worn  down  by  care  and  apprehension.  I  was  con- 
vinced, I  say,  by  all  these  circumstances,  that  amputation 
could  have  done  nothing  worse,  and  may  have  done  mu»h 
better. 

An  early  diagnosis  is  all-important,  and  the  points  in  dif- 
ferentiation from  periostitis  are  the  following: 

1.  In  periostitis  the  area  of  thickening  is  more  circum- 
scribed and  more  irregular  in  outline. 

In  periosteal  sarcoma  the  thickening  soon  embraces  the 
whole  circumference  of  the  bone. 

2.  In  periostitis  the  superficial  parts  present  more  signs  of 
an  acute  inflammation. 

In  sarcoma  the  superficial  parts  present  little  in  the  way 
of  extra  heat  or  other  inflammatory  signs. 

3.  The  pain  in  periostitis  diminishes  in  direct  ratio  with 
the  growth  of  the  tumor. 


168  DISEASES  OF  THE  HIP. 

In  sarcoma  the  pain  increases  with  the  growth  of  the 
tumor.  . 

4.  Suppuration  is  the  rule  in  periostitis;  the  exception  in 

sarcoma. 

The  diagnosis  in  the  advanced  stages  is  not  difficult.  Of 
course  the  joint  may  be  so  enveloped,  and  the  functions  of 
the  same  may  be  thereby  so  much  impaired,  that  chronic 
articular  ostitis  may  be  diagnosticated. 

In  the  early  stage  of  central  ostitis  very  few  signs  present 
that  are  in  any  way  similar  to  those  of  a  sarcoma.  A  differen- 
tial diagnosis  here  is  rarely  called  for;  but  there  are  certain 
points  in  common  between  the  two,  where  the  diseases  are 
more  advanced.  For  instance,  I  saw  a  boy,  four  years  of 
age,  last  spring,  with  a  bony  enlargement  of  the  femur,  and 
I  am  not  yet  fully  decided  as  to  whether  it  is  a  periosteal 
sarcoma,  a  chronic  osteo-myelitis,  or  a  chronic  articular  osti- 
tis in  the  second  stage.  When  I  first  saw  the  case  there  was 
uniform  thickening  of  periosteum,  it  seemed,  in  the  whole 
circumference  of  femur  in  its  middle  and  upper  thirds.  The 
trochanter  was  very  prominent,  yet  the  joint  surfaces  were 
smooth  and  in  normal  apposition.  When  I  saw  the  case 
again,  three  months  afterwards,  the  bony  enlargement  was 
the  same,  yet  there  was  a  large,  fluctuating,  movable  tumor 
on  the  posterior  surface  of  the  thigh.  I  did  not  have  an 
opportunity  of  exploring  the  tumor.* 

1.  In  the  second  stage  of  a  chronic  articular  ostitis,  the 
tumor  is  either  circumscribed  or  distinctly  fluctuating  over 
a  large  area. 

In  a  periosteal  sarcoma  the  tumor,  as  a  rule,  takes  in  the 
whole  circumference  of  the  bone,  and  if  fluctuation  be  pres- 
ent, it  will  be  over  a  very  limited  area,  and  more  than  one 
of  these  areas  will  be  found. 

2.  The  superficial  veins  in  the  one  are  not  prominent;  in 
the  other  they  get  to  be  enormously  distended. 

3.  As  the  tumor  increases  in  the  one,  the  general  health 
does  not  suffer;  as  it  increases  in  the  other,  cachexia  and 
emaciation  become  the  more  marked. 

4.  In  abscess  from  bone  disease  the  pain  is  at  no  time  very 
severe,  and  when  it  does  occur  it  occurs  during  exacerbations. 
In  sarcoma  the  pain  is  progressive,  and,  as  a  rule,  constant 
and  severe. 

*  Dr.  John  A.  Wyeth  informs  me  that  the  abscess  has  been  opened, 
and  that  the  case  now  presents  the  features  of  a  general  ostitis  gf  the 
shaft, 


MALIGNANT  DISEASE  OF  THE  HIP.  169 

5.  The  hypodermic  needle,  or  the  needle  of  the  aspirator, 
will  enable  one  to  make  a  differential  diagnosis  when  other 
means  fail. 

To  quote  Dr.  Gross:  "Finally,  a  rapidly-increasing,  pain- 
ful, lobulated,  soft,  elastic,  non-pulsating,  pyriform  or  fusi- 
form tumor,  especially  if  seated  on  the  shaft  of  a  long  bone, 
occurring  at  about  the  twenty-third  year,  and  unaccompanied 
by  fracture,  but  marked  by  discoloration  of  the  skin,  enlarge- 
ment of  the  subcutaneous  veins,  involvment  of  the  lymphatic 
glands,  and  elevation  of  temperature,  may  be  safely  ranked 
among  the  periosteal  round-celled  sarcomas." 


CHAPTER  XI. 
CHRONIC  ARTICULAR  OSTITIS  OF  THE    HIP. 

(SYNONYMS:  MORBUS  COXARIUS  ;  MORBUS  COX.E  ;  HIP- 
JOINT  DISEASE;  HIP  DISEASE;  TUBERCULOUS  DISEASE  OF 
THE  HIP;  CHRONIC  EPIPHYSITIS  OF  THE  HIP;  MEDULLO- 
ARTHRITIS;  COXALGIA;  COXITIS). 

PATHOLOGY. 

Whatever  name  surgeons  employ  to  represent  the  dis- 
ease in  question,  all  recognize  the  fact  that  its  essential 
feature  sooner  or  later  is  a  destruction  by  inflammatory 
process  of  the  bones  entering  into  the  articulation.  Its 
nature,  at  least  in  the  advanced  stages,  is  too  well  recog- 
nized to  admit  of  any  argument  at  this  late  day. 

I  employ  the  term  chronic  articular  ostitis,  because  I  be- 
lieve it  better  represents  the  pathology. 

The  time  has  come  when  Science  demands  a  definition  of 
the  terms  we  employ.  Hip-disease  has  too  vague  a  mean- 
ing. Too  many  distinct  diseases  are  included  in  this  term. 
Men  talk  glibly  about  curing  hip-disease,  and  we  find  that 
they  can  give  no  clear  idea  of  just  what  they  mean. 

So  of  morbus  coxarius,  and  morbus  coxae — the  Latin 
equivalents  merely.  All  are  objectionable,  although  popu- 
lar. Coxalgia  means  pain  at  the  coxo-femoral  articulation  ; 
coxitis,  inflammation  without  regard  to  the  tissues  prima- 
rily involved;  chronic  ephysitis  answers  very  well  if  we  can 
always  rest  satisfied  that  the  epiphysis  is  the  only  bone  in- 
volved in  the  initial  lesion.  We  know  too  well  that  the 
diaphysis  and  the  acetabulum  are  often  simultaneously 
implicated.  Hence  my  objection  to  the  use  of  the  term.  Tu- 
berculous disease  of  the  hip  is  formidable  enough,  and  may 
convey  the  proper  idea;  but  on  this  side  the  Atlantic  we  are 
unprepared  as  yet  to  accept  the  conclusions  in  full  of  our 
German  co-workers  in  this  field  of  pathology.  Some  of  us 
may  believe,  and  with  good  reason,  too  that  all  osseous  le- 
sions in  the  neighborhood  of  this  joint  are'not  tuberculous. 
The  name  I  have  chosen  will,  I  think,  more  clearly  accord 


CHRONIC  ARTICULAR  OSTITIS :    PATHOLOGY.      I/I 

with  accepted  views,  and  will  not  commit  us  absolutely  to 
one  form  of  inflammation.  The  time  has  also  come,  I 
think,  when  a  careful  examination,  with  a  full  understand- 
ing of  a  history,  of  signs,  and  of  symptoms,  will  enable  us 
to  recognize  the  disease  in  its  early  stage,  despite  the  ob- 
jections of  the  general  surgeon.  Errors  will,  of  course, 
arise,  yet  they  will  be  highly  instructive  to  him  who  strives 
to  make  this  branch  of  surgical  science  an  art  in  the  fullest 
sense  of  the  term. 

When,  then,  I  use  the  term  chronic  articular  ostitis  of 
the  hip,  I  want  my  readers  to  understand  that  I  mean  a 
bony  lesion  to  begin  with,  and  a  chronic  process;  hence  an 
insidious  disease  and  one  difficult  with  which  to  grapple.  I 
mean,  too,  to  convey  the  idea  that  no  one  bone  is  always 
the  seat  of  the  initial  lesion. 

To  the  pathology  of  this  disease,  then,  I  propose  to  de- 
vote a  few  pages,  and  I  make  no  claim  to  any  originality. 
To  name  the  different  views  of  writers  would  be  tedious  and 
unnecessary.  /The  text-books  on  general  surgery  supply  this 
want,  and  every  student  is  supposed  to  leave  college  with 
an  understanding  that  there  are  two  theories  prevalent; 
one,  that  this  disease  begins  as  a  simple  inflammation  in  the 
soft  parts,  the  ligamentum  teres  or  capsular  ligament  pref- 
erably, or  in  the  synovial  membrane  or  cartilage,  induced  by 
a  sprain,  or  wrench,  or  contusion,  however  slight;  the  other, 
that  it  begins  as  a  chronic  ostitis  of  a  strumous  nature  in 
one  or  more  of  the  centres  of  ossification  in  the  immediate 
neighborhood  of  the  articulation.  It  may  be  caused  by 
sprain  or  concussion,  but  frequently  arises  without  these 
factors,  and  is  aggravated  after  the  full  development  of  the 
disease  by  trauma.  For  an  excellent  resume  of  the  views 
held  and  facts  furnished  by  different  authors,  see  a  paper 
by  Dr.  Judson,  in  New  York  Medical  Journal  and  Obstetri- 
cal Review,  for  July,  1882,  entitled,  "  Some  Practical  In- 
ferences from  the  Pathology  of  Hip  Disease." 

The  arguments  employed  in  favor  of  an  inflammation  in 
the  soft  tissues  of  the  joint  being  primary,  and  inducing, 
either  by  interference  with  the  blood  supply  or  by  contigu- 
ity, a  chronic  ostitis  in  the  acetabulum  or  head,  have  never 
been  convincing  to  my  mind,  and  hence  this  theory  has  not 
been  accepted  in  my  pathology.  Pathological  specimens, 
I  am  well  aware,  are  adduced  to  prove  that  the  initial  lesion 
was  in  the  round  ligament.  These  instances  are,  with  a 
single  exception,  in  specimens  where  section  of  the  bone 


\ 
DISEASES   OF  THE  HIP. 

has  not  been  made.  The  exception  is  in  the  case  of  Dr, 
Willard's.  I  shall  present  his  conclusions,  with  comments, 
however,  a  little  later. 

An  epiphysitis,  and  especially  a  chronic  epiphysitis, 
wherein  the  inflammatory  exudations  encroach  upon  the 
blood-vessels,  must,  of  necessity,  produce  a  hyperaemia  of 
the  ligamentum  teres,  which  carries  the  blood  in  a  great 
measure  to  said  epiphysis,  and  this  hyperaemia  cannot 
long  remain  without  the  usual  inflammatory  changes. 

In  his  work  on  Diseases  of  the  Joints,  Mr.  Barwell  states 
emphatically:  "  In  no  case  of  ostitis  about  the  epiphysis 
have  I  ever  found  the  round  ligament  other  than  entirely 
absorbed,  thinned  and  inflamed,  or  ulcerated  and  hanging 
in  shreds;"  and  to  this  view  he  is  my  authority  for  stating 
that  Mr.  Aston  Key  gave  the  weight  of  his  authority. 

Without  entering  into  an  elaborate  argument,  I  think 
that  thoughtful  and  practical  surgeons,  the  world  over,  will 
agree  with  me  when  I  assert  that  the  injuries  done  this  lig- 
ament in  cases  where  a  clear  and  unmistakable  diagnosis 
can  be  made  at  the  time  of,  or  very  soon  after  the  occur- 
rence of  the  injury,  in  children  at  least,  terminate  in  reso- 
lution, with  or  without  the  "  absolute  rest"  so  zealously 
insisted  upon  by  the  orthopedist.  On  the  other  hand,  all 
men  know  that  there  are  cases  of  disease  at  the  hip-joint  that 
do  not  make  a  perfect  recovery,  even  if  the  most  successful 
orthopedist  gets  them  under  treatment  the  moment  the 
first  white  blood-corpuscle  wanders  from  its  channel  to  light 
up  disease. 

That  disease  may  begin  in  the  synovial  membrane  and 
extend  by  contiguity  to  the  bone  I  am  as  well  convinced 
as  symptomatology  and  clinical  facts  can  convince  one,  but 
I  am  unable  in  my  study  of  pathology  to  adduce  a  single 
case  either  from  my  own  records  or  from  literature  that 
will  prove  beyond  a  doubt  that  such  a  process  takes  place. 
Still,  it  is  my  belief,  based  on  clinical  records  and  compar- 
ative pathology,  that  many  of  the  bone  diseases  about  the 
hip  occurring  in  children  over  eight  years  of  age  are  in- 
duced by  synovitis  or  periostitis.  Some  I  find  myself  that 
seem  clear,  and  yet  I  cannot  feel  absolutely  certain.  An 
acute  epiphysitis  may  in  these  very  cases  be  the  original 
disease,  and  the  synovitic  symptoms  may  be  such  as  we 
find  developing  in  the  course  of  a  chronic  epiphysitis. 

Take  the  following  case,  in  a  boy  ten  years  of  age,  in  whom 
I  diagnosticated,  with  a  precautionary  interrogation-mark 


CHRONIC  ARTICULAR  OSTITIS  :   PATHOLOGY.       173 

however,  acute  primary  synovitis.  He  was  admitted  to  the 
hospital  in  February,  1881,  and  was  so  excessively  tender 
about  his  hip  that  it  required  the  greatest  amount  of  care 
to  get  him  into  the  ward  without  pitiful  shrieks.  After 
much  coaxing  he  was  induced  to  stand.  The  left  limb  was 
rotated  outward  over  a  small  arc,  and  the  foot  was  everted. 
It  was  slightly  flexed,  and  by  reason  of  the  pelvic  accom- 
modation was  apparently  one  and  a  half  inches  longer 
than  its  fellow,  while  careful  measurements  from  the  an- 
terior superior  spine  revealed  nearly  a  half  inch  shortening. 
There  was  no  atrophy,  and  while  there  was  unmistakable 
joint  tenderness,  most  of  the  soreness  on  moving  the  limb 
was  periarticular.  Along  Poupart's  ligament  the  glands 
were  infiltrated  quite  distinctly,  and  along  the  inner  side  of 
the  thigh  the  parts  were  apparently  swelled,  yet  measure- 
ments failed  to  verify.  The  gluteal,  the  iliac,  and  the  ilio- 
costal  regions  were  free  from  any  infiltration.  While  all 
movements  were  resisted,  any  attempt  at  passive  motion 
excited  pain  which  was  referred  to  the  distribution  of  the 
anterior  crural  and  the  obturator  nerves.  The  adductors 
stood  out  prominently  tense.  There  was  some  febrile  re- 
action but  it  was  not  measured. 

One  month  previously,  while  apparently  in  good  health, 
and  without  any  provocation,  he  complained  one  morning 
of  pain  in  his  knee,  but  walked  to  school  as  usual  though 
limping.  The  lameness  and  the  pain  increased  during  the 
day  and  next  day,  so  that  on  the  third  day  he  was  quite 
unable  to  walk.  His  sleep  was  not  disturbed  unless  he 
moved  in  the  bed.  The  symptoms,  according  to  the  father, 
had  been  growing  steadily  worse.  With  this  history,  then, 
with  the  liabilities  to  cold  at  that  season  of  the  year 
(Christmas  time),  and  with  those  symptoms  many  of  which 
were  those  of  synovitis,  I  felt  reasonably  sure  that  here  I 
had  a  genuine  case  of  primary  synovitis,  and  I  made  a 
favorable  prognosis. 

The  treatment  adopted  was  such  as  I  had  used  with 
success  in  others,  viz.,  blistering,  poulticing,  and  rest.  He 
grew  rapidly  worse,  and  within  a  month  the  infiltration  had 
extended  throughout  the  upper  portion  of  the  thigh.  By 
the  last  of  Mayan  immense  abcess  had  formed  and  opened 
near  the  junction  of  the  upper  with  the  middle  thirds  of 
the  thigh.  The  pus  was  brownish  in  color  and  had  a  fecal 
odor.  The  deformity  had  increased  and  the  hip  was  prac- 
tically locked  against  any  motion,  active  or  passive. 


174  DISEASES  OF  THE  HIP. 

The  boy  was  taken  away,  and  I  have  heard  that  he  died 
shortly  after  removal.  I  have  reported  already  in  the 
chapter  on  bursitis,  page  115,  a  case  wherein  the  disease  of 
a  bursa  underlying  the  ilio-psoas  was  the  cause,  in  my 
opinion,  of  the  joint  disease,  the  final  results  of  which 
have  not  been  reached. 

Under  seven  or  eight  years  of  age  the  vast  majority  of 
cases  of  so-called  hip-disease  begin  as  an  ostitis.  Beyond 
that  age  a  certain  proportion,  not  large  as  I  have  already 
stated,  begins  as  a  bursitis,  a  synovitis  or  a  periostitis, 
while  still  a  large  number  begin  as  a  central  bone  disease. 
At  all  events,  be  the  starting  point  what  it  may,  the  peculiar 
richness  of  the  blood  supply  in  the  cancellous  structure  of 
the  bone,  the  temporary  hyperaemias  in  and  about  the 
centres  of  ossification,  induced  by  over-use  or  external  vio- 
lence, and  the  recognized  existence  of  a  diathesis,  make 
the  transition  from  health  to  disease  at  times  extremely 
easy. 

The  experiments  of  M.  Oilier,  in  Number  X.  of  the 
Revue  de  Chirurgie,  1881,  showed  how  easily  disturbing 
forces  could  affect  the  epiphysis,  i.e.,  could  induce  hyper- 
ffimia — the  initial  stage  of  inflammatory  changes.  Dr.  Jno. 
Jas.  Berry,  formerly  associated  with  me  in  hospital  work 
has  written  during  the  past  year  in  the  New  England 
Medical  Monthly  a  very  instructive  paper  entitled,  "  Juxta 
Epiphysal  Congestion  in  its  relations  to  Hip-Disease."  He 
makes  use  of  the  following  remark,  which  I  can  in  a  great 
measure  confirm: 

"We  must  remember  that,  whereas,  in  adults,  the  liga- 
ments and  cartilage  suffer  from  the  shock  of  injuries,  in 
children, concussion  affects  the  weakest  portion  of  the  articu- 
lation, which  is  the  epiphysis.  Added  to  such  injury  there 
is  crushing  of  the  dense  enclosing  layer  and  effusions  of 
blood  into  the  medullary  spaces."  The  promptness  of  such 
injuries  to  resolve,  I  think,  is  well  demonstrated,  and  when 
they  do  not  thus  terminate  one  naturally  assumes  a.  cons- 
titutional diathesis.  It  does  not  always  result  in  carious 
deposits  even  in  strumous  children,  for  there  are  various 
degrees  of  resistance.  Hereditary  qualities  and  conditions 
of  health,  hygienic  surroundings  and  peculiar  conditions 
of  the  atmosphere  make  the  individual,  and  this  tissue  in 
particular,  a  fit  receptacle  for  the  lodgment  of  the  bacillus 
which  is  found  in  strumous  matter. 

Then,  again,  certain  acute  diseases  increase  this  vascu- 


CHRONIC  ARTICULAR  OSTITIS :    PATHOLOGY.      17$ 

larity  in  structures  wherein  rapid  developmental  changes 
occur  and  bring  about  practically  the  same  result  as  do 
concussions  and  other  injuries. 

This  is  well  illustrated  in  a  case  reported  by  Dr.  Willard 
of  Philadelphia,  in  the  Boston  Medical  and  Surgical  Journal, 
1880,  and  in  which  the  microscopical  work  was  done  by 
Dr.  Shakespeare  of  the  same  city.  The  article  was  entitled 
"  Hip-Joint  Disease:  Death  in  Early  Stage  from  Tubercular 
Meningitis."  The  child  was  five  years  of  age,  and  phthisis 
and  bad  hygiene  were  found  in  the  history.  Lameness  and 
other  signs  of  joint  disease  began  one  year  prior  to  Dr. 
Willard's  observations  in  the  case.  From  his  examination 
he  concluded  that  there  was  "  presumptive  evidence  that 
the  round  ligament  is  the  centre  of  the  disease."  The 


FlG.  10. — ACKTABULUM  AND  HEAD  OF  FEMUR,  SHOWING  DISCOLORED  SPOT  ON    LATTER. 

patient  was  confined  to  bed  with  weight  and  pully,  and 
every  facility  utilized  for  securing  good  hygiene.  Two 
months  later  tubercular  meningitis  developed,  and  after  a 
very  acute  attack,  lasting  six  days,  the  patient  died.  The 
specimen  is  of  such  great  interest  that  I  have  reproduced 
it  in  its  gross  appearances. 

"There  was  not  more  than  ten  drops  of  effusion,  but  the 
synovial  membrane  was  everywhere  congested  and  soft- 
ened, and  at  the  acetabular  attachment  of  the  ligamentum 
teres  were  decided  evidences  of  inflammation  and  softening 
of  tissues.  Upon  the  head  of  the  femur,  on  its  posterior 
upper  surface,  was  a  discolored  patch  (Fig.  10)  possibly 


176  DISEASES   OF  THE  HIP. 

caused  by  post-mortem  contact  against  the  acetabutum, 
although  there  was  no  corresponding  spot  in  that  cavity, 
and  it  had  more  the  appearance  of  redness  situated  beneath 
the  articular  cartilage.  The  capsule  was  perfect,  the  round 
ligament  intact,  and  while  the  membrane  covering  it  was 
more  reddened  and  softened  than  at  any  other  part,  yet 
there  were  no  positive  signs  of  ulceration  to  the  naked 
eye."  "After  decalcification  of  the  hard  parts  and  harden- 
ing of  the  soft  tissues,"  Dr.  Shakespeare  made  a  section  of 
the  acetabulum  and  head,  at  the  same  time  cutting  longi- 
tudinally the  ligamentum  teres. 

The  epiphysis  did  not  contain  to  the  naked  eye  any  ca- 
seous or  other  nodules,  the  cartilage  was  entire,  there  was 
nothing  macroscopical  in  any  of  the  tissues  suggestive  of 
miliary  or  confluent  tubercles. 

Among  the  conclusions  arrived  at  from  microscopical  ex- 
aminations of  this  specimen  was  that  the  bony  structure  of 
the  neck  of  the  femur,  although  hypersemic,  was  but  slightly 
diseased  and  not  tuberculous,  and  that  a  few  caseous  foci 
were  found  in  the  ligamentum  teres,  but  these  were  not 
tuberculous.  Indeed,  about  the  only  condition  actually 
found  was  a  somewhat  exaggerated  hypersemia  throughout 
all  the  tissues.  Pathologically,  it  was  negative. 

Now,  while  the  conclusions  arrived  at  by  the  two  gentle- 
men reporting  the  case  are  perfectly  legitimate,  I  am  con- 
strained to  regard  it  as  one  in  which  the  pathological  pro- 
cesses that  existed  early  in  the  disease  (this  had  begun 
already  a  year  before  coming  under  Dr.  W.'s  treatment) 
were  in  that  slow,  inactive  state,  and  under  the  favorable 
hygiene  latterly  provided,  had  undergone  a  cfertain  degree 
of  resolution,  all  to  be  disturbed  again  and  provoked  to 
renewed  activity  by  the  invasion  of  the  acute  tubercular 
meningitis.  This  disease,  it  will  be  seen,  proved  fatal  in 
one  week,  and  hence  time  had  not  been  sufficient  for  any 
extensive  lesions  from  original  foci  of  the  chronic  disease. 

The  centres  of  ossification  are  fertile  soil  for  the  develop- 
ment of  strumous  (tuberculous)  processes.  The  resem- 
blance of  this  cancellous  texture  to  the  parenchyma  of 
lung  is  very  striking,  and  the  clinical  characters  of  tubercle 
in  the  two  localities  have  been  brought  in  close  comparison 
within  the  past  year  by  Mr.  Scovell  Savory,  one  of  the  sur- 
geons to  St.  Bartholomew's  Hospital.  He  published  his 
notes  on  page  737  of  volume  II.  of  the  Lancet  for  1882.  The 
structure  of  the  two  tissues  is  sponge-like,  yet  the  resem- 


CHRONIC  ARTICULAR  OSTITIS  :    PATHOLOGY.      177 

blance  becomes,  the  stronger  when  a  mass  of  yellow  tuber- 
culous-looking matter  occupies  the  substance. 

Mr.  Savory  speaks  further  of  the  halo  of  inflammation 
or  increased  vascularity  by  which  each  is  surrounded,  vary- 
ing in  width.  I  have  myself  seen  this  so  often  in  bone 
with  caries  and  rarifying  ostitis.  This  is  very  difficult  to 
show  without  colored  lithographs,  and  hence  the  ordinary 
plates  seem  tame  and  inconclusive.  The  author  from  whom 
I  have  just  quoted  goes  still  further  in  his  comparison: 
"Just  as  pleurisy  is  so  often  set  up  by  the  disturbance  of 
tubercle  in  the  lung,  so  synovitis  is  often  provoked  by  the 
disturbance  of  tubercle  in  adjacent  bone;  and  just  as  em- 
pyema  is  sometimes  produced  by  the  perforation  of  the 
lung-wall  and  the  escape  of  matter  into  the  pleural  cavity, 
so  suppuration  in  a  joint  which  is  too  often  destructive  is 
due  to  the  perforation  of  the  articular  wall  of  bone  and 
the  escape  of  matter  into  the  synovial  cavity." 

The  researches  of  Volkmann  establish,  so  far  as  speci- 
mens from  the  joint  and  the  bones  entering  into  the  forma- 
tion of  the  joint  removed  by  excision  at  all  stages  of  the 
disease  can  establish,  the  truth  of  the  theory  that  the  great 
proportion  of  all  cases  begin  by  small  localized  centres  of 
disease  at  or  near  the  centre  of  ossification.  The  nature  of 
these,  histologically,  is  tuberculous. 

My  own  studies  lead  me  to  the  conclusion  that  the  centres 
of  disease  are  nearer  the  diaphyso-epiphysial  line.  In  a  case 
that  I  had  for  a  time  under  observation  with  Dr.  C.  T.  Poore 
of  this  city,  and  subsequently  published  by  that  gentleman 
in  the  Medical  Record,  this  localized  centre  of  disease  is 
shown  in  the  accompanying  figure  No.  n. 

The  patient  was  a  girl  aged  five  years,  and  began  to  com- 
plain of  pain  in  her  right  lower  limb  in  the  early  part  of 
December,  1878.  The  family  history  was  poor,  and  the 
hygiene  had  been  wretched.  There  was  no  existing  cause, 
so  far  as  could  be  ascertained.  The  pain  and  lameness  were 
synchronous,  and  the  stiffness  was  especially  marked  in  the 
morning.  When  I  saw  her  first  it  was  on  the  i4th  of  De- 
cember, and  I  found  both  lower  limbs  very  hyperaesthetic, 
the  right  the  more  notably  so.  I  saw  her  again  nearly  one 
month  later.  She  seemed  very  helpless,  and  the  report 
from  the  mother,  who  was  herself  exceedingly  hysterical, 
was  that  the  child  had  been  screaming  while  asleep,  and 
even  waking  out  of  sleep  crying,  as  if  suffering  terribly, 
every  night  since  I  had  seen  her  last;  that  the  lamenessjiad. 


1/8  DISEASES  OF  THE  HIP. 

increased,  and  that  she  was  losing  flesh.  I  saw  that  she 
was  much  thinner  than  when  I  had  examined  her  before. 
The  left  thigh  now  was  advanced  a  little  and  the  foot  evert- 
ed. Extension  to  the  normal  limit  was  resisted,  other 
movements  were  not.  Two  days  later  there  was  dulness  in 
the  left  ilio-costal  span,  but  in  the  absence  of  other  signs 
was  not  significant.  The  lameness  and  pain  on  walking, 
and  the  morning  stiffness  were  still  present.  Pain  and  re- 
sistance were  encountered  when  the  left  thigh  was  rotated. 
Two  days  elapsed  again  and  the  right  thigh  was  adducted, 


Fio.  ii.— SPECIMEN  OF  DIAPHYSO-EPIPHYSITIS  FROM  CASE  REPORTED  ON  PAGE  177. 

the  foot  was  inverted,  and  there  was  marked  resistance  to 
flexion  beyond  90°.  The  same  resistance  was  present  on 
the  left  side.  As  she  stood,  both  limbs  were  in  moderate 
genu-vulgum,  and  the  right  natis  was  flattened  and  crease 
lowered,  while  the  lameness  was  marked  in  the  left  limb. 
Tenderness  at  either  hip  or  at  either  sacro-iliac  synchon- 
drosis  was  absent  by  any  test  employed.  Indeed,  there  was 
no  sign  present  on  one  side  that  was  not  present  on  the 
other,  and  this  circumstance  wai>  duly  recorded. 

In  a  couple  of  days  she  was  again  submitted  to  a  thorough 
examination,  and  the  greatest  tenderness  elicited  was  over 
the  left  sacro-iliac  junction.  Motion  at  the  left  hip  caused 
no  pain.  Even  the  severe  test  of  putting  on  and  off  the 


CHRONIC   ARTICULAR   OSTITIS :     PATHOLOGY.      179 

stocking  caused  no  pain,  and  forcibly  percussing  the  heel 
with  limb  extended  induced  laughter.  On  attempting  to 
stoop,  pain  was  complained  of  at  the  left  knee,  and  as  she 
stood  this  limb  was  apparently  longer.  Next  day  Dr.  Poore 
saw  the  case  with  me,  and  he  noted  that  "  nothing  wrong 
could  be  detected  about  either  hip-joint;  motion  free  and 
painless  in  all  directions,  except  that  she  complained  of 
some  pain  in  the  knee  when  the  left  thigh  was  strongly 
flexed.  When  the  left  joint  was  moved  patient  made  no 
complaint,  but  when  the  left  ilium  was  pressed  inward  she 
cried  out  from  pain.  There  was  no  swelling  about  the 
right  or  left  hip-joint;  no  change  in  the  crease  of  the  natis. 
The  right  hip-joint  seemed  perfectly  healthy.  There  was 
pain  on  pressing  the  crest  of  the  ilium  on  the  left  side  in- 
ward, referred  to  the  left  knee,  or  upon  ?'  -npting  to  com- 
municate motion  to  the  sacro-iliac  joint  o~  ihatside.  There 
was  tenderness,  or  at  least  the  patient  complained,  on 
pressure  being  made  over  the  sacro-iliac  synchondrosis  of 
the  left  side,  and  there  appeared  to  be  some  dulness  on  per- 
cussion over  that  joint;  none  on  the  right.  In  walking  or 
standing  she  favored  the  left  limb,  but  there  was  nothing 
characteristic  in  her  attitude." 

On  the  24th  of  February  I  saw  her  with  Dr.  P.,  and  noted 
that  motion  at  hip  (left)  was  limited  in  flexion  and  exten- 
sion to  smaller  arcs  than  normal,  and  in  abduction  and  ad- 
duction to  scarcely  appreciable  arcs;  that  with  the  excep- 
tion of  the  tenseness  of  the  adductors,  the  same  signs  were 
found  at  the  right  hip.  I  could  not  discover  any  atrophy 
or  shortening.  The  joint  surfaces  on  both  sides  were 
smooth,  however,  in  the  limited  arcs  of  motion. 

During  the  latter  half  of  Marcli  there  was  much  pain 
about  the  right  knee,  and  the  limb  was  held  flexed  as  the 
child  lay  in  bed.  Adduction  became  a  strongly-marked 
sign  on  each  side. 

I  assisted,  one  day  early  in  April,  the  Doctor  in  making  a 
pretty  thorough  examination  under  ether.  The  adductor 
contraction  yielded  with  very  little  force,  but  in  our  man- 
ipulations the  right  hip  was  subluxated.  While  there  was 
entire  absence  of  articular  roughening  at  either  joint,  this 
giving  way  of  the  ligamentum  teres  was  the  only  sign  we 
could  discover.  The  urine,  a  few  days  subsequently,  was  ob- 
served to  be  dark  and  smoky.  The  patient  died  on  the  i6th, 
and  after  twenty  hours  post  mortem,  we  found  the  limbs 
perfectly  straight  and  equal  in  length.  The  parts  on  section 


I8O  DISEASES  OF  THE  HIP. 

down  to  the  capsule,  right  side,  were  normal  in  appearance. 
The  head  could  be  easily  slipped  out  of  the  socket,  and  as 
easily  returned.  The  capsular  ligament  itself  was  intact,  but 
on  being  opened  was  found  to  contain  about  two  drachms 
of  thick,  inodorous  pus.  The  ligamentum  teres  was  softened, 
pretty  thoroughly  disorganized,  and  about  two  lines  of  it 
was  attached  to  the  head,  while  the  proximal  portion  lay 
spread  out  on  the  floor  of  the  acetabulum.  On  passing  the 
finger  over  this  portion  of  the  acetabulum  an  area  of  bare, 
roughened  bone,  a  half-inch  in  diameter,  could  be  felt,  and 
one  blade  of  a  small  pair  of  forceps  passed  readily  through 
without  force,  the  point  of  the  blade  being  felt  by  a  finger 
inserted  through  the  sacral  foramen.  The  cartilage  cover- 
ing the  head  was  yellowish  but  nowhere  eroded.  Section 
of  the  head  and  neck  was  made,  and  nothing  abnormal  to 
the  naked  eye  was  observed. 

The  left  hip-joint  was  exposed,  and  its  capsule  was  found 
normal  in  every  respect.  No  fluid  escaped  when  it  was 
opened,  and  the  head  could  only  be  turned  out  of  the  socket 
with  considerable  force  and  with  the  characteristic  suction 
sound.  Its  complete  dislocation  was  impossible,  without 
dividing  the  ligamentum  teres.  This  ligament  was  pale  red 
in  appearance  on  section,  and  seemed  normal  in  size, 
strength  and  attachments.  The  articular  cartilages  were 
pearly  white,  and  apparently  normal.  The  same  means 
with  the  finger  and  forceps  were  made  to  detect  erosion  or 
disease  in  the  acetabulum,  as  were  made  on  the  right  side, 
with  absolutely  negative  results. 

On  removing  the  capsular  ligament  at  its  femoral  attach- 
ment, a  worm-eaten  hole  was  discovered  on  the  upper  border 
of  the  neck  just  at  its  junction  with  the  head,  and  into  this 
hole  the  point  of  a  lead  pencil  could  be  inserted  without 
force.  On  section  of  bone,  a  yellowish  (caseous  [?])  patch 
was  seen  involving  the  upper  portion  of  the  diaphysis, 
encroaching  upon  the  diaphyso-epiphysial  cartilage  and 
even  above  this  line  within  the  medulla  of  the  epiphysis 
there  was  a  similar  patch,  the  two  only  separated  by 
the  cartilage.  This  diaphysial  patch  communicated  with 
the  joint  by  means  of  the  small  hole  above  mentioned. 
There  was  no  pus.  A  vascular  areola  existed  about  this 
patch,  shading  off  into  the  normal  bony  tissue.  (See 
Fig.  n.)  On  opening  the  abdominal  cavity,  the  bladder 
was  seen  above  the  pubis  but  not  distended.  Pressure 
upon  this  viscus  was  immediately  followed  by  a  discharge 


CHRONIC  ARTICULAR   OSTITIS  :     PATHOLOGY.      l8l 

of  at  least  a  half  ounce  of  whitish  very  fetid  pus  from  the 
vagina.  The  bladder  contained  about  an  ounce  of  clear 
normal-looking  urine,  and  its  walls  appeared  normal.  A 
pus-sac  was  found  between  the  bladder  and  the  vaginal 
wall  opening  into  the  latter.  This  sac  had  been  cut  away 
by  the  dissection,  and  its  direct  connection  with  the  per- 
forated acetabulum  could  not  be  made.  The  whole  inner 
surface  of  the  pelvis  was  carefully  exposed  and  no  evidence 
of  disease  about  the  ramus  of  the  pubis,  the  symphysis,  or 
either  sacro-iliac  junction  could  be  discovered.  My  own 
explanation  of  the  source  of  the  abscess  is  that  the  pus  bur- 
rowed behind  the  obturator  muscle,  as  it  sometimes  does. 
(See  Fig.  6,  arrow  C),  and  found  its  way  into  the  ischio- 
rectal  fascia.  In  the  female  the  vagina  perforates  the  recto- 
vesical  fascia  and  receives  a  prolongation  from  it.  It  would 
be  just  as  easy,  then,  for  the  pus-sac  to  open  into  the  vagina 
as  in  the  rectum,  between  which  there  is  no  fascial  layer. 

I  have  been  thus  particular  in  detailing  this  case,  making 
it  even  fuller  in  some  respects  than  it  was  when  first  pub- 
lished, because  I  find  it  so  very  instructive  and  so  illustra- 
tive of  the  pathological  processes  that  take  place.  In  the 
first  place  the  subject  would  pass  anywhere  for  a  strumous 
child,  and  yet  no  exciting  cause  could  be  found. 

Again,  the  ostitis  developed  in  the  acetabulum  of  one 
side,  and  in  the  diaphysis  of  the  other  side,  very  nearly 
about  the  same  time.  In  other  words,  there  was  a  multiple 
lesion,  and  the  foci  of  disease  were  in  close  proximity  to 
centres  of  ossification.  From  the  acetabulum  there  were 
quite  early,  though  not  appreciated,  signs  of  synovitis. 
Indeed,  the  process  here  was  more  acute  than  in  the  femur, 
and  the  inflammatory  processes  extended  the  more  rapidly 
to  neighboring  parts,  involving  the  synovial  membrane  on 
the  one  hand  and  the  pelvic  fascia  on  the  other;  a  little 
later,  the  ligamentum  teres.  It  will  be  observed,  too — and 
this  fact  I  want  to  stand  out  in  bold  relief — that  although 
the  ligamentum  teres  was  thoroughly  diseased  and  disorganized, 
the  nutrition  of  the  epiphysis  suffered  no  appreciable  change. 
The  acetabulum  was  not  the  tissue  to  suffer  from  disease 
of  this  ligament,  and  yet  it  was  perforated. 

The  process  going  on  in  the  left  femur  was  much  slower, 
and  was  what  some  might  describe  as  a  caries  sicca.  But 
how  do  we  know  that  this  would  have  been  so  had  the 
process  in  the  right  acetabulum  been  less  acute  ? 

It  is  seldom  that  the  ostitis  pursues  so  rapid  a  course 


1 82  DISEASES  OF  THE  HIP. 

as  it  did  in  this  particular  case,  yet  cases  have  their 
counterpart  in  pulmonary  tissues.  Often  the  lesion  seems 
arrested,  and  cases  with  long  intermissions  are  not  at  all 
uncommon.  Cases  like  the  following  come  under  observa- 
tion, and  during  the  interval  between  exacerbations  a  cure 
is  often  pronounced.  The  boy  was  four  years  of  age  at 
the  time  of  admission  to  the  hospital  in  March,  1871.  It 
is  recorded  that  he  had  a  brother  suffering  from  caries  of 
the  hip,  well  advanced  into  the  destructive  stage.  They  re- 
port that  a  year  prior  to  admission  our  patient  fell  from  a 
velocipede  about  one  year  prior  to  admission,  and  a  few 
months  later  complained  of  pain  in  the  right  knee.  This 
became  severe,  and  was  referred  to  the  hip,  causing  the 
usual  night  screens,  the  morning  stiffness,  etc. 

Condition  on  entrance  to  hospital  as  follows:  plump, 
and  well  nourished;  boy  standing  with  the  right  lower  ex- 
tremity semiflexed,  everted,  and  resting  on  the  toes,  and 
walking  with  a  very  marked  limp;  nates  on  right  side 
broadened,  natural  depressions  effaced,  crease  raised,  and 
cleft  inclined  to  the  left;  thigh  flexed  on  pelvis  at  an  angle 
of  150°,  and  held  here  by  muscular  action,  though  flexion 
can  be  carried  to  90°  without  causing  much  pain.  The 
diagnosis  is  made  without  reservation,  and,  under  the 
usual  treatment  of  the  hospital,  the  case  made  good  prog- 
ress; though  in  the  month  of  May  there  occurs  without 
known  cause  a  suppurative  middle-ear  disease,  left  side. 

At  the  close  of  the  first  week  in  September  it  is  noted 
that  his  condition  is  such  as  to  justify  his  discharge,  and  a 
month  later  his  general  health  seems  excellent;  he  stands 
squarely  on  both  feet,  and  walks  without  a  trace  of  lame- 
ness; no  atrophy  exists,  no  tenderness  or  pain  on  complete 
flexion  or  extension,  or  on  concussion  of  trochanter — in 
fact,  no  sign  of  disease  in  or  about  the  hip  can  be  detected. 
His  friends  had  deserted  him,  and  no  home  could  be  found; 
hence,  he  remained  in  the  hospital,  different  persons  prom- 
ising to  adopt  him,  until  the  beginning  of  1875.  During 
that  period  never  a  sign  of  disease  was  observed,  and  the 
cure  was  regarded  as  well  established.  The  ear  disease 
continued,  however,  after  the  usual  manner. 

On  the  first  day  of  January,  1875,  note  is  made  of  an  en- 
largement of  cervical  glands  right  side  three  months'  stand- 
ing, coming  on  without  any  known  cause,  and  steadily 
gaining  ground  despite,  all  treatment.  Hip  still  free  from 
any  sign  of  disease. 


CHRONIC  ARTICULAR  OSTITIS :    PATHOLOGY.      183 

Next  day,  after  perfect  immunity  for  three  years  and 
three  months,  the  hip  is  the  seat  of  great  pain,  and  the  boy 
is  abed  with  a  high  temperature,  and  crying  if  any  motion 
at  the  joint  be  attempted. 

The  acute  symptoms  were  relieved  by  the  middle  of  the 
month,  and  the  boy  was  walking  around  the  ward,  though 
joint  still  tender  and  glandular  infiltration  increasing.  A 
general  glandular  enlargement,  or,  adenia,  set  in,  the  boy 
became  emaciated  to  a  skeleton,  and  death  by  asthenia 
occurred  the  last  day  of  February. 
•  Autopsy  twenty-four  hours  later,  conducted  by  Dr.  Ed- 


I 

FIG.  12. — VERTICAL  SECTION  OF  PROXIMAL  END  OF  NORMAL  FEMUR  IN  CASE  ON 
PAGE  184. 

ward  G.  Janeway.  Body  greatly  emaciated,  and  skin 
jaundiced  about  eyes,  scrotum  and  right  lower  extremity; 
both  lower  limbs  lie  in  complete  extension,  and  motion  at 
joints  is  free. 

Right  lung  slightly  oedematous,  otherwise  normal,  and 
old  pleuritic  adhesions  are  extensive;  left  lung  and  pleura 
normal,  as  also  the  heart.  Peritoneal  cavity  contains  about 
a  pint  of  a  yellowish  jelly-like  material;  liver  is  one  fourth 
larger  than  normal,  and  on  the  surface  as  well  as  on  section 
there  is  a  mottled  appearance. 

In  the  gastro-hepatic  omentum  a  gland  the  size  of  a 
walnut  presses  against  the  ductus-communis  choledochus, 


1 84 


DISEASES   OF  THE  HIP. 


the  pyloric  orifice  of  the  stomach  and  the  receptaculum 
chyli.  The  microscopic  appearances  of  this  gland  are 
normal.  Mesenteric  glands  enlarged,  as  likewise  the  cer- 
vical, from  the  mastoid  process  to  the  clavicle,  varying  in 
size  from  a  hazel-nut  to  a  walnut.  A  deeper  gland  sep- 
arates the  deep  jugular  from  the  carotid,  a  space  of  one 
inch,  and  presses  against  the  pneumogastric.  Pus  is  found 
in  the  right  middle  ear,  extending  into  the  mastoid  cells. 

The  right  hip-joint  being  opened,  the  capsular  ligament 
is  found  intact;  there  is  no  fluid  within  the  cavity,  and  suc- 
tion force  is  normal,  while  the  ligamentum  teres  is  easily 
detached.  Head  of  bone  presents  a  dirty  yellowish  aspect, 
with  a  groove  extending  from  ligamentum  teres  towards 


FIG.  13.— VERTICAL  SECTION  SHOWING  Foci  OF  DISEASE  IN  CASE  ON  PAGE  184. 

trochanter  minor,  intersecting  a  similar  groove  about  the 
insertion  of  capsular  ligament.  In  this  groove  is  new  con- 
nective tissue.  At  one  point  the  cartilage  is  completely 
eroded;  head  flattened.  On  vertical  section  there  appear 
three  yellowish  spots,  two  above  and  one  below  the  line 
of  epiphysial  union,  which  line  of  union  is  carried  up  one 
inch;  cartilage  is  one  half  the  normal  thickness,  and  this, 
as  well  as  the  bone  underlying,  is,  in  the  field  of  the  micro- 
scope, seen  to  be  in  the  process  of  fatty  degeneration. 
The  head  and  neck  of  the  sound  femur  are  also  removed 


CHRONIC  ARTICULAR  OSTITIS :     PATHOLOGY.      185 

and  the  above  description  is  comparative.  Blood  exam- 
ined microscopically  and  found  normal.  The  accompany- 
ing cuts  show  very  strikingly  the  pathological  changes, 
with  the  exception  of  the  coloring.  The  whitish  spots  in 
the  head  and  neck  of  Fig.  13  in  the  original  sketch,  as  made 
by  the  artist  at  the  post-mortem,  are  yellowish,  showing  the 
fatty  metamorphosis  to  perfection.  Fig.  12  is  a  section  of 
the  sound  bone  inserted  for  comparison. 

The  case  of  Fricke's,  of  Hamburg,  published  in  1833,  I 
take  from  Dr.  Judson's  paper,  is  of  value  in  this  connec- 
tion. The  boy  was  four  years  of  age  and  had  been  lame 


FIG.  14. — SECTION    OF    SOUND  FEMUR    TO 
FRICKB'S  CASE.    COMPARB  WITH  FIG.  13. 


FIG.  is.— -SECTION  OF  FEMUR  m  FRICKK'I 
CASE.    PAGE  185. 


four  months,  when  he  died  of  tubercular  meningitis.  Lon- 
gitudinal section  was  made  of  each  femur  and  is  repre- 
sented in  the  copies  from  colored  lithographs.  Fig.  14  the 
sound;  Fig.  15  the  diseased.  He  found  the  synovical  mem- 
brane everywhere  red  and  congested.  The  articular  carti- 
lage was  healthy  in  all  its  surfaces,  whue  the  spongy  tissue 
of  the  upper  portion  of  the  femur,  throughout  its  whole 
extent,  was  much  redder  and  more  vascular  than  that  of  the 
sound  femur.  A  firm  yellowish  or  grayish-white  mass  was 
seen  in  the  interior  of  the  neck  occupying  the  greater  part 
of  the  medulla,  and  taking  the  place  of  the  spongy  tissue. 


186 


DISEASES  OF  THE  HIP. 


At  its  upper  portion  it  was  retained  in  contact  with  the  com- 
pact layer  of  the  neck  of  the  femur,  but  loosely  enough  for  a 
probe  to  pass  between;  the  lower  portion  of  this  mass  was 
firmly  adherent  to  the  spongy  tissue.  The  epiphysial  car- 
tilage was  greatly  reduced  in  thickness. 

M.  Larinelongue's  case  published  in  1881,  in  the  Bulletin 
Of  the  Surgical  Society  of  Paris  (vol.  ii.  No.  i.  pp.  9-11,) 
Illustrates  the  close  connection  between  the  diaphysial  lesion 
and  the  fungous  localized  synovitis.  This  abstract  I  also 
take  from  Dr.  Judson's  paper.  The  patient,  a  girl,  three 
and  a  half  years  of  age,  had  been  lame  two  and  a  half  months 
and  the  hip  was  locked  in  the  flexed  and  adducted  position. 
Five  months  after  the  invasion  of  the  joint  disease  she  died 
of  diphtheria,  and  the  synovial  membrane  was  found,  post 

mortem, reddish, thickened, 
and  fungoid  in  appearance, 
in  certain  places,  especial- 
ly at  its  lower  and  posteri- 
or portion.  The  synovial 
changes  appeared  to  M. 
Lannelongue  to  start  from 
the  neck  of  the  femur  near 
the  head.  The  ligamen- 
tum  teres  was  also  red, 
vascular  and  slightly  fun- 
gous. The  surfaces  of  head 
and  acetabulum  presented 
no  change,  and  the  articular  cartilages  retained  their  normal 
condition,  with  the  exception  of  a  little  thinning  on  cer- 
tain portions  of  the  head. 

Section  of  head  and  neck  revealed  a  marked  redness  in 
the  centre  of  ossification  of  the  head  and  large  areolae  in 
comparison  with  those  of  the  opposite  side.  The  promi- 
nent feature  of  the  specimen  was  a  cavity  the  size  of  a  small 
bean  lined  with  thin  membrane  and  filled  with  a  cheesy 
substance,  situated  immediately  below  the  epiphysial  carti- 
lage. The  bony  tissue  around  the  cavity  presented  a  red 
zone.  From  certain  portions  of  this  lining  membrane  of 
the  cavity  fungosities  started  and  reached  the  surface  of 
the  bone,  where  they  became  continuous  with  the  thick- 
ened synovial  membrane. 

Volkman  has  published  a  case  the  specimen  from  which 
(Fig.  16)  is  similar  to  Fricke's.  (See  p.  1406,  Saml.  Klin. 
Vortrag.  Nos.  168,  169,  1879.)  It  is  described  by  the 


FIG.  16. — VOLKMANN'S  CASE.    PAGE  186. 


CHRONIC  ARTICULAR  OSTITIS  :   PATHOLOGY.       187 

author  as  having  a  cavity  in  the  neck  of  the  femur  immedi- 
ately under  the  epiphysial  cartilage,  which  cavity  is  lined 
with  smooth  tuberculous  membrane  and  filled  with  cheesy 
matter. 

The  term  ostitis  malacissans  is  the  term  Billroth  prefers 
for  the  early  changes,  and  Volkman  employs  for  the  same 
the  term  rarefying  ostitis.  The  chalky  salts  quickly  dis- 
appear from  the  osseous  tissue,  and  the  medullary  vessels 
increase;  the  medulla,  being  filled  with  wandering  cells 
takes  the  place  of  the  disappearing  bony  tissue  (Billroth). 
This  is  directly  the  opposite  of  ostitis  osteoplastica.  In 
the  one  softening  of  the  bone-substance  occurs,  and  in 
the  other  the  neoplastic  tissue  is  transferred  into  compact 
bone. 

The  form  of  inflammation  with  which  we  have  to  deal  is 
not  the  osteoplastic  ostitis,  but  the  ulcerative  and  the  fun- 
gous. Caries  is  only  employed  to  represent  the  destructive 
stages  of  an  ostitis.  It  represents  the  bony  defects  caused 
by  the  lacunar  erosions.  Caries  begins  as  an  ostitis,  and  is 
known  as  such  by  some  authors,  Billroth  preferring  to 
abandon  the  term  altogether  and  modify  the  term  ostitis 
to  express  the  different  kinds  one  meets  both  clinically  and 
on  the  dissecting-table. 

If,  then,  a  rarefying  ostitis,  which  produces  always  a  soft- 
ening of  the  bone  substance,  is  characterized  by  proliferat- 
ing granulations,  and  does  not  go  on  to  suppuration,  we  call 
this  a  caries  sicca,  or,  an  ostitis  fungosa.  If,  on  the  other 
hand,  the  rarefying  ostitis  goes  on  to  suppuration,  the  neo- 
plastic material  disintegrating  or  undergoing  carious  meta- 
morphosis— this  we  call  caries  atonica.  Frequently  masses 
of  bone  become  separated,  and  the  process  is  called  caries 
necrotica.  Indeed,  as  repair  goes  on,  and  these  disinte- 
grated portions  are  exfoliated  we  have  particles  of  necrotic 
bone  coming  away  with  the  pus  ;  so  that  a  really  distinct 
caries  is  comparatively  rare.  Both  clinical  experience  and 
post-mortem  anatomy  teach  clearly  that  no  one  form  is 
always  present  to  the  exclusion  of  the  other.  The  forms 
of  inflammation  blend  here  as  in  other  tissues. 

Billroth  claims  that  the  non-suppurating  caries,  the  fung- 
ous ostitis,  is  the  more  common  in  childhood,  while  the 
atonic  belongs  especially  to  adult  life.  My  own  views  are 
just  the  reverse  of  this.  He  states,  argumentatively,  "  Path- 
ological anatomists,  who  only  see  caries  on  the  dissecting- 
table,  rarely  know  the  fungous  form  accurately,  or  consider 


188  DISEASES   OF  THE  HIP. 

it  the  more  rare  ;  but  when  one  often  examines  pieces  of 
carious  bone,  cut  out  during  life,  especially  the  resected 
joints  of  children,  where  the  process  is  going  on  actively, 
he  learns  to  judge  differently  from  what  he  would  in  the 
anatomical  museums  where  macerated  bones  almost  exclu- 
sively are  preserved"  (p.  503,  Hackley's  Trans.). 

I  would  retort  by  asserting,  with  abundance  of  proof  to 
sustain  me  in  the  assertion,  that  at  least  three-fourths  of 
the  cases  of  chronic  articular  ostitis  of  the  hip  in  children 
do  suppurate,  and  the  reason  why  the  distinguished  Vienna 
surgeon,  and  other  surgeons  throughout  Germany,  do  not 
meet  with  the  atonic  form  of  caries  in  these  resected  speci- 
mens is,  that  they,  almost  with  one  accord,  operate  early, 
and  rarely  wait  for  the  suppurate  stage.  How  can  one  de- 
termine whether  the  process  he  sees  on  resection  would 
have  remained  as  it  is,  or  have  gone  on  to  caseous  degene- 
ration and  the  formation  of  tubercle  ? 

It  is  simply  impossible  to  say  in  every  given  case  of 
chronic  bone  disease  affecting  the  hip-joint,  and  I  might 
include  the  other  large  joints,  that  suppuration  will  not 
occur.  In  thirty  cases  of  caries  of  the  ankle  in  children 
that  I  have  analyzed,  twenty-five  suppurated.  (Am.  Jour- 
nal of  Obstetrics  and  Diseases  of  Women  and  Children, 
April,  1880.) 

The  changes  that  take  place  in  the  medullary  portions  of 
the  bone  in  the  vicinity  of  the  centres  of  ossification,  even 
in  the  fungous  ostitis,  certainly  cannot  long  resist  the  ten- 
dency to  suppuration.  Indeed,  Virchow  has  shown  that 
the  boundary  lines  between  the  medullary  cells  and  pus 
cells  cannot  be  sharply  defined.  (Cellular  Pathology.) 

The  development  from  one  to  the  other  is,  of  course,  hast- 
ened by  septicaemic  influences.  So  that  I  am  forced  to  the 
conclusion  that  it  is  exceedingly  difficult  to  differentiate 
from  clinical  evidence  between  a  caries  sicca,  and  a  caries 
atonica.  With  this  chronic  disease  marked  by  such  slowly 
developing  products  in  the  medulla  and  at  the  centres  of 
ossification — a  strumous  basis — the  development  of  tuber- 
cles is  an  easy  and  a  natural  process. 

Dr.  Henry  H.  Smith,  of  Philadelphia,  has  traced  the  con- 
nection, in  a  highly  instructive  paper,  presented  to  the 
American  Association  in  1878  (Transactions  for  that  year). 
He  notes  the  influence  of  congestion  of  the  medulla  on  the 
cell  proliferation,  and  on  the  increased  number  of  leuco- 
cytes ;  also  the  defective  elaboration  of  blood  as  a  result  of 


CHRONIC  ARTICULAR   OSTITIS :     PATHOLOGY.      189 

perverted  myeloid  cell  action  :  and  arrives  at  the  conclu- 
sion that  struma  and  tubercle  are  so  closely  allied  that  dif- 
ferences cannot  well  be  demonstrated.  Such  is  now  the 
accepted  view  of  the  nature  of  the  strumous  ostitis  of  the 
spongy  portions  of  bone. 

In  Germany,  I  am  informed  by  Dr.  Wm.  H.  Welch,  the 
question  is  long  since  regarded  as  settled,  and  further  inves- 
tigation is  deemed  useless. 

Given,  then,  the  caseous  degeneration,  what  becomes  of 
the  products,  and  how  does  the  process  extend  ?  Abscess 
forms,  the  cavity  is  lined  with  a  membrane  in  which  can  be 
sometimes  found  tubercles.  The  caseous  matter  contains 
bone  debris.  Parts  fall  together,  are  fused,  or  still  further 
destroyed. 

Harwell's  case,  in  a  boy  who  died  of  tuberculous  meningi- 
tis two  months  after  the  appearance  of  the  first  symptoms 
of  joint  disease,  is  detailed  on  page  276  of  the  Wood's  Li- 


FIG.  17. — SHOWING  RAPID  DESTRUCTION  OF  BONE  IN  HARWELL'S  CASK. 

brary  Edition.     The  specimen,  Fig.  17,  is  described  as  fol- 
lows : 

"What  remains  of  the  round  ligament  can  barely  be 
seen  ;  it  was  very  thin,  soft,  and  shreddy  ;  red,  and  infil- 
trated with  a  blood-stained  serum.  The  epyphysial  and 
diaphysial  head  of  the  bone,  with  a  portion  of  the'neck,  was, 
at  its  lower  part,  quite  carious  ;  the  excavation  shown  in 
the  figure  was,  when  fresh  filled  up  with  thick  pus,  mingled 
with  bony  detritus  and  soft  granulation  tissue.  The  carti- 
lage was  intact  though  thinned,  except  around  the  caseous 
cavity,  where  it  had  in  great  part  disappeared.  It  was  de- 
tached in  great  part  from  the  bone  for  a  considerable  dis- 
tance around  the  margins  of  that  excavation." 


1QO  DISEASES  OF  THE  HIP. 

Mr.  Holmes,  in  "  The  Surgical  Treatment  of  Children's 
Diseases,"  has  a  specimen  figured  which  closely  resembles 
Mr.  Harwell's.  The  drawing  was  made  from  the  bone  as 
removed  by  excision  from  a  girl  eleven  years  of  age  who 
had  been  lame  for  two  years.  Mr.  Holmes  describes 
it  as  a  case  in  which  the  disease  was  seated  wholly  within 
the  neck.  I  have  had  the  specimen  reproduced  in  Fig.  18. 

The  portion  of  bone  which  gave 
way  is  well  shown,  yet  I  am  not 
convinced  that  the  epiphysis  did 
not  contain  a  focus  of  caseous 
ostitis  inasmuch  as  no  mention 
is  made  of  a  section.  It  does 
not  follow  that  because  the 
"articular  surface  was  quite 
healthy"  a  mass  of  carious  bone 
did  not  lie  beneath  it  ready  to 
break  through  during  an  exacer- 
bation and  complete  the  destruc- 
tion of  the  joint.  The  compact 
tissue  of  the  neck  giving  way 

FIG.  ,8.-MR.  HOLMES'  SPECIMEN  TO  first>  this  case  g°6S  °n  re<T°rd  aS. 
ILLUSTRATE  CARIES  OF  THE  NECK,  one  of  the  femoral  Variety  of 
VERTICAL  SECTION  NOT  MADE.  i  •  •  •  .  j-  <T-U  j' 

hip-joint  disease.  The  disease 

may  be  such  that  the  whole  articular  cartilages  may  be 
shed.  This  occurs,  however,  in  the  acute  and  subacute  form 
of  an  epiphysitis.  Mr.  Barwell  has  figured  a  fine  specimen 
on  page  278  of  the  American  edition  of  his  work.  The  accom- 
panying figure  (19)  is  from  a  colored  lithograph  published 
by  Volkman  in  his  lecture.  Dr.  Judson  has  adduced  this 
as  an  example  of  the  spread  of  the  pathological  process 
from  the  centre  to  the  periphery  rather  than  the  reverse. 

The  neck  and  head  in  their  changes  are  altered  materi- 
ally ;  the  angle  the  neck  makes  with  the  shaft  becomes  acute 
sometimes,  often  it  becomes  rectangular,  and  the  tro- 
chanter  is  carried  above  Nelaton's  line,  giving  rise  to  the 
appearance  of  a  dislocation.  The  acetabulum,  if  not  prima- 
rily diseased,  occasionally  becomes  involved  from  contact 
with  the  necrotic  masses  filling  its  cavity. 

Dr.  Judson  reports  (page  7  of  his  pamphlet):  "  It  is  a  curi- 
ous fact,  and  one  which  has  not  received  the  attention  it 
deserves,  that  the  tables  of  exsection  of  the  hip  for  disease 
contain  a  large  number  of  cases  in  which  the'acetabulum  is 
reported  as  healthy."  In  Hodges'  table  of  one  hundred 


CHRONIC  ARTICULAR  OSTITIS :    PATHOLOGY.      19! 

and  eleven  operations,  there  were  sixteen  cases  wherein  the 
acetabulum  had  escaped  disease. 

In  a  case  the  specimen  from  which  is  shown  in  Fig.  20, 
the  acetabulum  and  remnant  of  head  were  fused  into  one 
homogeneous  mass. 

The  boy,  aged  twelve,  was  admitted  to  hospital  in  June, 
1875.  He  had  a  diathesis  typically  strumous  inherited 
and  acquired,  if  the  latter  were  necessary  to  complete  the 
condition.  Six  or  seven  years  before  admission  symptoms 


pIG<  ,g< FROM  VOLKMAN'S  COLORED  LITHOGRAPH,  SHOWING  EXFOLIATION  OP  ARTICULAR 

CARTILAGE. 

of  bone  disease  at  the  hip  developed.  Abscesses  formed, 
and  when  I  examined  him  the  joint  was  seemingly  an- 
kylosed,  the  angle  of  deformity  in  flexion  being  about  135°. 
Several  cicatrices  existed,  and  below  the  trochanter  there 
were  two  open  sinuses.  The  shortening  and  atrophy  were 
prominent  signs.  From  the  date  of  his  admission  to 
August,  1876,  the  case  ran  the  usual  course.  Abscesses 
would  refill,  sloughing  follow  about  the  gluteal  region,  and 
at  this  time  one  had  opened  below  the  anterior  superior 


IQ2  DISEASES  OF  THE  HIP. 

process  and  above  Poupart's  ligament.  Later,  ulcers 
formed  over  the  coccyx  and  in  the  border  of  the  perineum. 
Indeed,  all  the  parts  about  the  joint  became  the  seat  of 
ulcers  or  cicatrices  or  areas  of  infiltration.  Head  symptoms 
were  frequently  noted,  and  during  the  next  two  years  the 
notes  show  many  exacerbations,  many  remissions.  Finally, 
in  August,  1878,  the  area  of  hepatic  dulness  increased. 


wmi  FIG  21 


'     REMNANTS  °*  HKAB,   NECK  AND  ACKTABULUM  FUSED  TO- 

AT  REPAIR-     TROCHANTER  DISPLACED  UPWARD.     COMPARE 


There  was  much  pain  in  this  region,  the  urine  for  two  or 
three  years  of  low  specific  gravity,  1008,  now  presented 
epithelium  and  blood,  but  no  casts.  In  September  he  had 
considerable  vomiting  and  diarrhcea,  and  in  October  he 
slowly  sank,  dying  by  asthenia  on  the  2ist.  Dr.  Janeway 
assisted  me  in  the  autopsy  ten  hours  after  death.  Drs. 
fcipley  and  Putzel  were  present.  The  left  femur  was  ex- 
posed and  an  attempt  made  to  tear  it  from  the  pelvis,  but 


CHRONIC  ARTICULAR  OSTITIS :     PATHOLOGY.      193 

it  seemed  so  intimately  associated  that  this  portion  of  the 
pelvis  was  removed  with  the  upper  portion  of  the  femur. 
The  inner  surface  of  the  ilium  showed  a  track  of  abscess, 
one  end  connecting  with  the  perforated  acetabulum,  the 
other  with  an  ulcer  above  Poupart's  ligament.  The  tro- 
chanter  major  was  very  prominent,  and  extended  one  and 
one  half  inches  above  the  corresponding  point  on  the  right 
side.  The  shaft  of  the  bone,  even  denuded  of  all  the  soft 
tissues,  was  held  firmly  in  adduction.  On  longitudinal 


FIG.  si. — SECTION  OF  THB  SOUND  FEMUR  IN  CASE  ON  PAGE  193,  TO  COMPARE  WITH 

FIG.  20. 

section  through  shaft  trochanter  and  portion  of  pelvis 
removed,  the  neck  was  absent,  and  only  about  one  half  of 
the  head  could  be  seen,  and  this  was  fused  with  the 
acetabulum,  the  outlines  of  which  were  very  indistinct, 
a  yellowish  border  shading  off  into  red,  taking  the  place 
of  the  normal  rim.  On  comparison  with  a  like  section  of 
the  parts  on  the  sound  side  the  difference  between  the  two 
hips  stood  out  in  fine  relief. 

The  trochanter  of  the  diseased  femur  seemed  to  be  on 
the  same  plane  with  the  head  of  the  sound  femur,  thus 


194  DISEASES  OF  THE  HIP. 

making  a  shortening  of  the  limb  of  between  two  and  three 
inches.  The  shaft  and  the  trochanter  were  perfectly  normal 
macroscopically. 

The  colored  sketch  from  which  the  drawing  represented 
in  Fig.  20  is  taken,  shows  the  osteophites  scattered  through- 
out the  caseous  mass,  and  is  a  fine  demonstration  of  the 
mode  in  which  destruction  and  reproduction  go  on  at  the 
same  time  in  even  the  atonic  caries  of  bone.  The  stage 
had  been  reached  in  this  case  when  the  reproduction  was 
in  excess  of  the  destruction.  But  for  the  development  of 
amyloid  disease  the  patient  would  have  made  a  recovery, 
with  a  very  useful  limb. 

The  spleen  was  normal  in  appearance,  but  the  kidneys 
had  adherent  capsules,  nodular  surfaces,  and  on  section  a 
marked  waxy  appearance  was  shown  in  the  cortex  and 
pyramids. 

The  liver  filled  the  greater  part  of  the  abdominal  cavity, 
and  the  right  lobe,  instead  of  presenting  a  very  sharp  bor- 
der, was  markedly  rounded.  (Text-books  make  this  point 
in  differential  diagnosis  during  life  between  waxy  and  fatty 
livers;  the  border  is  sharp  in  waxy,  rounded  in  fatty.  The 
explanation  given  is  that  the  organ  reaches  the  brim,  or 
fossa  of  the  pelvis,  and  not  being  able  to  get  lower,  the  bor- 
der is  turned,  so  to  speak.)  The  border  of  the  left  lobe  was 
sharp,  it  not  having  descended  into  the  pelvis.  The  weight 
of  the  liver  was  five  and  a  quarter  pounds.  The  upper  por- 
tion was  strongly  adherent  to  the  diaphragm.  On  section 
amyloid  changes  were  very  apparent  to  the  naked  eye. 

The  lungs  and  pleura  were  free  from  miliary  tubercles, 
though  in  the  middle  lobe  of  the  right  a  half-dozen  calcified 
nodules,  varying  in  size  from  a  pin's  head  to  a  small  mar- 
ble, could  be  felt,  apparently  plugging  the  bronchi. 

The  cranial  dura  was  lined  by  a  membrane  which  could 
be  easily  removed,  and  which,  on  microscopical  examination, 
was  found  to  consist  of  fully-organized  tissue  filled  with 
capillary  vessels.  No  tubercles  were  anywhere  found.  The 
bones  were  not  examined  microscopically.* 

The  destruction  of  the  acetabulum  is  well  shown  in  the 
specimens  represented  in  Fig.  22,  which  I  have  taken  from 
Barwell. 

*  This  case  was  reported  in  the  Medical  Record  for  November  3,  1877, 
as  one  of  "  Cure  of  Tubercular  Meningitis  by  Ergot,"  and  now,  two 
years  later,  the  post  mortem  showed  that  the  boy  had  had,  instead,  a 
simple  acute  internal  pachy-meningitis. 


CHRONIC  ARTICULAR  OSTITIS :     PATHOLOGY.      195 

The  specimen  as  shown  in  Fig.  23  represents  what  few  of 
us  have  had  an  opportunity  of  seeing,  viz.,  a  pus  sac  hang- 
ing from  the  inner  wall  of  the  acetabulum. 


FIG.  33. — CHANGES  TN  ACETABULUM  IN  THE  ADVANCED  STAGES. 

This  is  also  taken  from  Harwell. 

The  disease  ocasionally  extends  through  the  neck  into 
the  shaft,  and  Dr.  Poore  believes  that  we  have  an  osteo- 


196 


DISEASES  OF  THE  HIP. 


myelites  more  frequently  than  one  would  be  led  to  suspect. 
In  a  paper  on  excision  of  the  hip-joint,  published  in  the 
New  York  Medical  Journal  for  May,  1877,  this  author  re- 
ports two  or  three  cases  in  which  a  grave  osteo-myelitis 
existed.  In  one  case,  while  he  attempted  to  throw  the 
head  of  the  bone  out  of  the  acetabulum,  after  the  usual  in- 
cision had  been  made,  the  femur  was  fractured  at  the  junc- 
tion of  the  diaphysis  with  the  epiphysis,  just  above  the 


FIG-  23. — ABSCESS  FROM  ACETABULUM. 

knee-joint.  The  whole  shaft  was  removed  by  drawing  it 
through  the  original  opening.  The  cut  end  was  soft  and 
discolored.  It  happened  with  Dr.  Poore,  as  it  has  happened 
with  other  surgeons  whose  experience  in  excisions  is  large, 
on  making  his  section,  in  several  cases,  to  find  the  medul- 
lary canal  diseased.  Lower  sections  reveal  the  same  con- 
ditions not  infrequently. 

Mr.  Holmes  found  a  femur  in  a  case  reported  in  St. 
George's  Hospital  Reports,  Vol.  I.,  soft  and  diseased  at 
both  ends.  Dr.  Sayre,  in  fifty-nine  cases  of  excision,  found 
the  shaft  diseased  in  two-fifths  of  that  number. 

Dr.  Poore  significantly  remarks,  "  I  know  of  no  means  of 
ascertaining  the  condition  of  the  shaft  before  commencing 


CHRONIC  ARTICULAR   OSTITIS  :    PATHOLOGY.      197 

to  operate,  except  that  cases  of  disorganization  of  the  joint 
of  long  standing  should  be  looked  upon  with  suspicion." 

It  occasionally  happens,  also,  that  not  only  the  shaft  but 
the  pelvic  bones  are  diseased  throughout  a  greater  part  of 
their  structure.  Mr.  Armandale,  in  a  paper  on  Hip  Disease, 


FIG.  14.— SECTION  OF  FBMUH  IN  CASK  REPORTED  on  PAGB  198. 

states  that  he  has  met  with  two  cases  in  which  the  whole 
femur,  the  ilium,  and  probably  other  of  the  bones  were  dis- 
eased throughout  their  whole  structure. 

The  nature  of  the  ostitis  is  usually  the  same  in  mutiple 
lesions  of  the  spongy  bones,  and  the  accompanying  figure, 
No.  24,  shows  the  lesion  in  the  head  of  the  femur  nearer  the 


198  DISEASES  OF  THE  HIP. 

periphery  than  I  have  usually  found  the  initial  process. 
The  boy  from  whom  this  specimen  was  taken  had,  in  addi- 
tion, a  caseous  vertebral  ostitis,  a  similar  disease  of  the 
bones  of  the  foot,  and  a  tubercular  meningitis  from  which 
he  died.  He  was  ten  years  of  age  when  disease  of  the  foot 
appeared,  and  shortly  afterwards  the  spinal  symptoms  de- 
veloped. The  "knuckle"  was  not  observed  until  he  was 
twelve.  Six  or  eight  months  later,  signs  of  chronic  articular 
ostitis  of  the  left  hip  were  recognized.  In  a  few  months 
abscess  over  the  trochanter  formed.  Later  still,  cystitis 
appeared  and  yielded  to  treatment.  At  times  the  hip  and 
the  ankle  would  be  distended  with  fluid;  then,  an  exit  be- 
ing found,  they  would  seem  normal.  Reflex  symptoms  were 
never  a  marked  feature  of  the  case.  From  February,  1878, 
to  October,  1879,  he  led  at  his  home  a  vegetative  exis- 
tence. Then  he  developed  a  tubercular  meningitis,  and 
died  in  November.  The  wonder  was  with  his  prolonged 
emaciation,  his  ulcers  in  various  localities,  and  his  prolonged 
suppuration,  that  he  did  not  contract  amyloid  degeneration. 
There  was  no  phthisis,  however,  in  the  family  history,  so 
far  as  could  be  learned. 

The  autopsy  was  conducted  with  much  thoroughness, 
yet  the  full  notes  are  unnecessary  here,  and  a  bare  mention 
of  the  lesions  in  certain  organs  will  suffice.  The  brain,  for 
instance,  contained  the  lesion  both  macrospical  and  micro- 
scopical of  tubercular  meningitis. 

True  miliary  tubercles  were  found  in  the  pulmonary 
pleura. 

The  bodies  of  three  or  four  of  the  middle  and  lower 
dorsal  vertebrae  were  broken  down  and  generaly  disorgan- 
ized, and  a  caseous  cyst  connected  therewith  was  in  close 
proximity.  Over  the  liver  were  small  granular  bodies  pro- 
nounced by,  Dr.  Janeway,  to  whom  I  referred  all  the  speci- 
mens, miliary  tubercles. 

The  femur,  left  side,  was  denuded  of  periosteum  at  its 
middle  third  for  a  couple  of  inches,  and  this  area  connected 
with  a  fistulous  tract  opening  on  the  outer  side  of  the  thigh. 
On  careful  dissection,  the  capsular  ligament  was  found 
intact;  but  just  above  its  insertion,  and  above  the  upper 
margin  of  the  acetabulum,  was  an  opening  through  the 
ilium,  into  the  floor  of  the  acetabulum,  through  which  the 
eroded  head  of  the  femur  could  be  distinctly  seen,  and 
through  which  I  put  my  finger,  and  felt  this  carious  body 
move  as  I  rotated  the  shaft. 


CHRONIC  ARTICULAR  OSTITIS :    PATHOLOGY.      199 

Areas  of  denuded  bone  were  seen  all  along  the  external 
iliac  fossa,  and  even  up  to  the  sacro-iliac  synchondrosis. 

No  trace  of  the  ligamentum  teres  could  be  found.  Lying 
loose  in  the  acetabulum  were  several  small  pieces  of 
necrotic  bone  belonging  apparently  to  the  head.  On  cleans- 
ing the  cavity  of  these  fragments  no  erosion  of  the  acetabu- 
lar  cartilage  could  be  discovered  save  in  the  upper  portion 
above  mentioned.  In  the  triangular  space,  however,  for 
three  quarters  of  an  inch  in  diameter,  there  was  complete 
loss  of  bone  substance,  but  no  opening  into  the  pelvis. 
The  internal  periosteum  was  quite  thick  at  this  point. 
There  was  no  pus  or  other  fluid  in  the  joint  cavity. 

On  vertical  section  of  femur,  a  soft  pulpy  material 
filled  the  centre  of  the  trochanter,  and  a  similar  mass  occu- 
pied the  upper  end  of  the  shaft  at  the  centre  of  ossification. 

In  the  remnant  of  the  diaphyso-epiphysial  head  was  a 
yellowish  pulp  with  reddish  areolae  in  both  epiphysis  and 
diaphysis,  the  cartilage  separating  the  two  being  irregular. 
The  angle  of  the  neck  with  shaft,  was  apparently  un- 
changed. In  this  section  one  could  easily  see  the  different 
stages  of  a  rarefying  ostitis.  A  portion  of  this  pulp  micro- 
scopically presented  medulla  cells,  granular  and  fatty, 
with  an  occasional  giant  cell,  but  no  nucleated  blood  cor- 
puscles. 

The  tibio-tarsal  joint  was  intact;  the  medio-tarsal 
thoroughly  disorganized;  articular  cartilages  destroyed. 
The  greater  portion  of  the  scaphoid  remained,  while  the 
cuneiform  bones  were  reduced  to  one  half  the  normal  size. 
These  fragments  were  loose  and  easily  picked  out.  The 
cuboid  and  the  proximal  ends  of  all  the  metatarsal  bones, 
for  at  least  one  fourth  of  their  length,  were  eroded,  and 
lying  .in  thick  fetid  pus. 

The  internal  malleolus  was  enlarged,  but  not  eroded, 
while  on  section  all  the  cancellous  tissue  was  replaced  by 
pus,  pulpy  matter,  and  the  debris  of  carius  necrotica.  There 
was  no  opening  through  the  shell  of  compact  tissue. 

It  seems  fair  to  assume  that  central  ostitis  developed  in 
the  tarsal  and  metatarsal  bones,  and  in  the  bodies  of  the 
vertebrae  about  the  same  time.  The  inflammation  in  the 
bones  of  the  foot  extended  by  contiguity  to  the  tibio-tarsal 
synovial  membrane,  inducing  a  simple  synovitis,  which  re- 
solved like  any  other  simple  inflammation.  The  facts  I 
have  recorded  in  my  complete  notes.  The  opening  stook 
place  into  the  medio-tarsal  joint,  producing  here  a  puru- 


200  DISEASES  OF  THE  HIP. 

lent  synovitis  with  destruction  of  the  joint.  Pus  likewise 
escaped  into  the  periarticular  tissues,  and  we  had  chronic 
abscess.  The  malleolar  ostitis,  while  going  on  to  caseous 
degeneration,  did  not  perforate  the  outer  shell. 

The  femoral  diaphyso-epiphysitis  and  the  iliac  ostitis, 
seem  to  me  to  have  been  undoubtedly  primary  lesions  oc- 
curring, however,  two  or  three  years  subsequent  to  the  foot 
and  spinal  diseases.  The  synovitis  here  was,  I  think, 
secondary,  and  was  undoubtedly  purulent.  The  boy  had 
certainly  enough  caseous  foci  for  the  development  of 
tubercle  and  the  fatal  tubercular  meningitis,  although  no 
such  diathesis  was  traceable  in  the  family. 

The  further  destructive  changes  secondary  to  these  bone 
lesions  are  direct  and  indirect.  The  anaemia  is  one  of  the 
direct,  and  many  of  the  patients  who  die  of  this  disease, 
die  by  asthenia  after  prolonged  suppuration. 

Among  the  more  prominent  modes  of  termination  are 
exhaustion,  tubercular  meningitis,  amyloid  degeneration, 
phthisis.  In  one  hundred  and  fourteen  deaths  I  have  suc- 
ceeded in  tracing,  my  notes  show  that  fifty  patients  died 
from  pure  exhaustion  after  long  suppuration,  the  ostitis 
never  having  fully  subsided.  Twenty-six  died  from  tuber- 
cular meningitis,  and  generally  before  destructive  changes 
had  taken  place  in  the  joint.  Eighteen  died  of  amyloid 
degeneration  of  the  larger  viscera,  induced  by  prolonged 
suppuration.  Thirteen  died  of  intercurrent  ailments  not 
classified,  and  seven  died  of  phthisis.  Connection  between 
tuberculous  ostitis,  and  tuberculous  meningitis,  and  between 
prolonged  suppuration  and  amyloid  degeneration  I  have 
attempted  to  give  in  a  theoretical  way  in  the  chapter  on 
Etiology.  As  a  rule,  amyloid  changes  are  late  in  develop- 
ing* Yet  cases  are  on  record  in  which  they  may  appear  in  a 
few  months.  M.  V.  Odenius,  in  a  Sweedish  periodical,  the 
Nordist  Med.  Arkiv.  Bd.  XI.  No.  25,  reports  the  following: 

"A  case  of  traumatic  lesion  of  the  knee-joint  in  a  man, 
twenty-one  years  of  age,  who  had  always  before  been 
healthy;  the  injury  was  complicated  by  considerable  loss 
of  blood  and  perforation  of  the  synovial  sack. 

"  After  having  been  treated  for  some  time  at  his  native 
place,  and  not  in  the  most  rational  manner,  he  was  ad- 
mitted in  the  hospital  at  Lund.  He  was  excessively  ema- 
ciated, and  on  the  inner  side  of  the  right  knee  existed  a 
wound  of  some  size,  which  communicated  with  the  articu- 
lation, and  in  the  latter  was  a  large  abscess  filled  with  foul 


CHRONIC  ARTICULAR  OSTITIS :    PATHOLOGY.     2OI 

pus;  he  died  soon  after;  about  two  months  after  receipt  of 
the  injury. 

"  AUTOPSY. — Advanced  destruction  of  the  articular  cartil- 
ages, caries  of  the  bones  and  a  large  abscess  along  the 
femur  and  tibia;  in  the  kidneys,  amyloid  degeneration  of 
a  portion  of  the  corpora  malpighiana  and  their  vasa  affer- 
entia.  Traces  of  the  same  degeneration  were  likewise 
found  in  the  capillaries  of  the  spleen  and  their  immediate 
vicinity.  The  other  organs  exhibited  no  similar  changes, 
so  that  it  is  to  be  assumed  that  the  degeneration  mentioned 
was  directly  dependent  upon  the  osseous  lesion,  as  in  Cohn- 
heim's  celebrated  case.  The  conclusion  at  which  we 
arrive  is  that  this  degeneration  can  develop  itself  within 
a  period  of  two  months." 

It  is  not  very  uncommon  to  find  tuberculous  degeneration 
and  amyloid  degeneration  exist  in  the  same  subject.  The 
so-called  amyloid,  or,  lardacine  is  closely  allied  to  albumen, 
differing  from  this  substance  in  its  insolubility  in  acids 
containing  pepsine  (Billroth  and  Kuhne). 

When  death  does  not  ensue  by  any  of  these  processes 
repair  takes  place  by  the  elimination  of  the  fluid  contents 
of  these  caseous  patches,  by  reproduction  of  bone  in  the 
form  of  osteophites,  by  condensation  of  periarticular 
tissues  ligaments  and  periosteum,  and  by  the  fusing  to- 
gether of  the  neoplasia,  forming  a  synostosis,  or,  what  is 
more  common,  a  joint  practically  ankylosed  by  fibrous 
tissues. 

The  conclusions  to  which  I  have  arrived  are: 

1.  The  large  majority  of  cases  of  chronic  articular  ostisis 
occur  in  childhood  prior  to  the  eighth  year. 

2.  In   these   the  initial  lesion  is  an  ostitis  interna,  the 
focus  of  disease  being  in,  or  in  close  connection  with,  the 
centres  of  ossification. 

3.  The  head  and  neck  of  the  femur  are  more  often  in- 
volved than  the  acetabulum. 

4.  It  is  rare  for  a  single  centre  of  ossification  to  be  in- 
volved, but  usually  two  or  more  are   implicated  at  very 
nearly  the  same  time. 

5.  The  ostitis  is  a  rarifying  ostitis,  and  may  terminate  in 
a  caries  atonica  or  a  caries  sicca,  the  former  being  the 
more  frequent. 

6.  Synovitis  is  secondary,  and  if  developed  by  contiguity 
is  simple,  and  if  by  the  perforation  of  the  cartilage  or  com- 
pact layer,  is  purulent. 

l-h  I  £•{ C 


2O2  DISEASES  Of  THE  HIP.    • 

7.  In  children  beyond  the  age  of  eight  years  the   initial 
lesion    is   about  equally   divided  among  a  central  ostitis 
a  periostitis,  a  chondritis  and  a  synovitis. 

8.  The  process,  whether  central  or  otherwise,  is  exceed- 
ingly slow,  and  proceeds  to  the  destruction  of  the  joint  and 
displacement  of  remaining  portions  of  bone. 

9.  If  the  patient  inherit  a  tubercular  diathesis  he  is  in 
danger  of  tubercular  meningitis    prior  to  the  occurrence 
of  suppuration  and  to  amyloid  degeneration  subsequent  to 
this  stage. 


CHAPTER  XII. 

THE  ETIOLOGY  OF  CHRONIC  ARTICULAR  OSTITIS. 

The  causation  of  chronic  joint  disease  in  childhood  will 
always  occupy  an  attitude  of  great  importance  in  ortho- 
pedic surgery.  Whether  there  exists  in  all  cases,  or  in  the 
great  majority  of  cases,  a  diathesis  known  as  strumous  or 
scrofulous,  which  acts  as  a  predisposing  cause  ;  or  whether 
this  has  no  connection  save  an  incidental  one — this  is  the 
question  that  meets  one  at  every  turn  in  connection  with 
these  maladies.  That  there  must  be  an  exciting  cause  few 
will  deny.  That  the  exciting  cause  is  always  trauma,  and 
that  a  predisposing  cause,  even  with  this  as  a  factor,  is  un- 
necessary, few  their  be  rash  enough  to  assert  such  a  proposi- 
tion. There  has  been  and  there  continues  to  be  much  useless 
controversy  in  relation  to  this  subject.  One  class  arrays 
itself  on  the  side  of  traumatism,  the  other  on  the  side  of 
scrofula.  The  lines  are  not  sharply  defined — one  does  not 
know  exactly  how  the  other  defines  his  terms.  When  the 
traumatist  says  that  the  majority  of  joint  diseases  come 
from  a  fall  or  an  injury,  the  impression  is  given  that  a 
strumous  habit  or  a  constitution  otherwise  vitiated  has 
nothing  specially  to  do  in  their  development. 

When  the  adherent  to  the  scrofulous  origin  of  joint 
diseases  presents  his  views  the  impression  is  given  that  all 
spring  from  hereditary  predisposition. 

It  is  curious  to  note  the  differences  of  opinion  on  this 
very  subject,  and  I  am  quite  sure  that  these  differences 
spring  from  an  imperfect  understanding  of  the  terms.  The 
terms  strumous  and  scrofulous  are  considered  to  hold  a 
certain  relationship  to  tuberculosis,  and  the  relationship  is  by 
no  means  clearly  understood.  This  subject  has  been  handled 
in  a  masterly  way  by  Mr.  Frederick  Treves,  of  London,  in  a 
work  published  in  this  series.  From  his  work  one  gets,  I 
think,  a  clear  idea  of  what  "tubercle"  is,  what  is  meant  by 
"  tuberculous,"  and  what  relationship  "scrofula"  holds  to  this 
condition.  I  shall  therefore,  without  going  into  the  details 


204  DISEASES   OF  THE  HIP. 

of  the  discussion,  simply  give  the  histology  of  tubercle, 
and  then  the  conclusions  reached  by  his  investigations. 

Tubercle  "  is  composed  of  a  mass  having  a  finely 
rounded  outline,  and  made  up  principally  of  cells.  These 
cells  are  so  arranged  as  to  form  in  typical  specimens  three 
zones.  The  central  part  is  occupied  by  one  or  more  giant- 
cells,  round  this  is  a  zone  of  many  so-called  epithelial 
cells,  and  beyond  this  is  a  third  zone  of  simple  embryonic 
cells  or  leucocytes.  All  these  cell  elements  are  supported 
by  a  fine  reticuleum,  which  is  generally  concentrically  ar- 
ranged at  the  periphery,  and  towards  the  centre  is  observed 
to  be  continuous  with  the  processes  that  commonly  come 
off  from  the  giant-cells.  The  affected  district  is  non- 
vascular.  Such  is  a  typical  tubercle."  And  yet,  from  the 
modifications  in  this  structure  and  from  the  fact  that  giant- 
cells  may  be  met  with  under  the  most  varied  circumstances 
and  conditions  where  we  can  in  no  way  term  them  tuber- 
cular, the  conclusion  is  reached  that  tubercle  presents  no 
distinctive  specific  anatomical  element. 

The  conformation  of  the  mass,  the  grouping  of  its  parts 
and  its  history,  its  tendency  and  evolutions — all  these  and 
more  determine  its  individuality. 

To  construct  a  brief  definition  of  scrofula,  or,  as  I  prefer 
to  call  it,  struma,  is  exceedingly  difficult.  I  believe  I  am 
safe  in  stating  that  all  authors,  with  one  or  two  exceptions, 
regard  as  synonymous  the  adjectives  strumous  and  scroful- 
ous. ^Esthetically,  I  prefer  the  former,  and  shall  conse- 
quently use  the  term  scrofulous  as  infrequently  as  possible. 
To  understand  what  the  term  means  is  not  difficult.  We 
recognize  it  as  a  tendency,  a  diathesis,  and  when  one  speaks 
of  a  strumous  diathesis  we  understand  him  as  speaking  of 
struma,  which  I  shall  proceed  to  define. 

Struma,  then,  is  a  diathesis  in  an  individual  either  here- 
ditary or  acquired,  which  renders  its  subject,  especially 
in  childhood,  peculiarly  vulnerable  in  certain  tissues, 
viz.,  the  mucuous  membrane,  the  skin,  the  lymphatic 
system,  and  the  bones,  and  the  inflammation  which  is 
so  easily  induced  in  the  tissues  named,  is  remarkable  for 
its  great  pertinacity  and  for  products  which  are  notably 
cellular  in  character,  which  present  certain  peculiar  prop- 
erties when  inoculated  on  animals,  and  which,  instead  of 
terminating  in  resolution  or  suppuration,  extend  locally 
and  infect  adjacent  parts,  developing  either  into  tubercles 
or  degenerating  into  caseation. 


CHRONIC  ARTICULAR  OSTITIS :    ETIOLOGY. 

Call  this  diathesis  a  tendency  if  you  will ;  it  can  scarcely 
be  called  a  disease.  That  it  is  recognized  by  certain  cha- 
racteristics all  must  admit.  It  is  impossible  fora  physician 
to  be  long  connected  with  a  dispensary  or  hospital  in  a  large 
city  without  coming  to  the  conclusion  that  some  vice,  either 
hereditary  or  acquired,  must  underlie  the  constitutions  of 
the  vast  majority  of  the  poor  who  seek  medical  assistance. 
In  one  instance,  the  shape  and  configuration  of  the  head 
attract  your  attention  ;  in  another,  the  peculiar  expression 
of  the  eye,  the  hue  of  the  face,  the  irregularity  of  the  teeth; 
in  another  instance,  the  contour  of  the  chest,  the  general 
carriage,  etc.,  etc.  It  is  difficult,  in  fact,  to  predicate 
strumous  of  one  particular  type  of  expression.  Some  chil- 
dren who  are  undoubted  subjects  of  this  diathesis  have 
light  hair,  and  some  have  dark  hair;  the  skin  in  some  is 
almost  transparently  light,  in  others  it  is  very  dark. 

The  experimental  inoculation  of  tubercular  and  strumpus 
products  have  been  conducted  by  such  men  as  Villemin, 
Burdon  Sanderson,  Wilson  Fox,  Klein,  Cohnheim,  Hueter 
Schiiller,  Klebs  and  Deutschman,  and  the  results,  so  far  as 
they  affect  the  relationship  of  the  two  conditions,  may  be 
summed  up  (to  quote  from  Mr.  Treves)  as  follows: 

"  i.  That  tubercular  matter,  when  introduced  into  the 
bodies  of  certain  animals,  can  produce  at  first  a  local  disease 
not  distinguishable  from  scrofula." 

M.  Kiener,  in  "L'Union  M6dicale"  for  1881,  p.  316,  has 
shown  that  the  injection  of  tubercular  matter  into  the  testis 
can  induce  caseous  inflammation  of  that  body,  and  into  the 
knee  joint,  a  chronic  joint  disease  that  fully  accords  with 
the  common  notions  of  white  swellings.  Cohnheim's  ex- 
periments have  all  the  same  bearing,  although  these 
observers  may  refrain  from  applying  the  term  scrofulous 
to  the  results  produced. 

.  "  2.  That  scrofulous  matter  when  used  as  a  vehicle  for 
inoculation  can  produce  general  tuberculosis. 

"  3.  That  tubercular  matter  acts  more  vigorously  in  these 
experiments  than  does  strictly  scrofulous  matter. 

"  From  these  results  it  may  be  gathered  that  experimental 
inoculation  maintains  the  identity  of  scrofula  with  tuber- 
culosis, and  at  the  most  can  only  show  that  the  two  condi- 
tions differ  somewhat  in  intensity  and  degree." 

If  we  conclude,  then,  as  many  observers  seem  to  have  es- 
tablished, that  struma  is  the  soil,  tubercle  the  seed  (and  it 
is  especially,  many  think,  exclusively,  upon  the  soil  of 


\ 
206  DISEASES  OF  THE  HIP. 

struma  that  the  infective  tubercle  can  take  root  and 
develop),  we  must  accept  the  conclusions  Mr.  Treves 
draws  as  to  the  relationship,  viz  : 

"  i.  The  manifestations  of  scrofula  are  commonly  asso- 
ciated with  the  appearance  of  tubercle  ;  or,  if  no  fully 
formed  tubercle  be  met  with,  a  condition  of  tissue  obtains 
that  is  recognized  as  being  preliminary  to  tubercle.  Ana- 
tomically, therefore,  scrofula  may  be  regarded  as  a  tuber- 
culous, or  tubercle-forming  process. 

"  2.  The  form  of  tubercle  met  with  in  scrofulous  diseases 
is  usually  of  an  elementary  and  often  of  an  immature  cha- 
racter, whereas  in  disease  called  tuberculous  in  a  strict 
clinical  sense,  a  more  perfect  form  of  tubercle  is  met  with 
in  the  form  of  the  gray  granulation,  or  adult  tubercle 
(Grancher). 

"  3.  Scrofula  therefore  indicates  a  milder  form  or  stage  of 
tuberculosis,  and  the  two  processes  a're  simply  separated 
from  one  another  by  degree." 

There  is  no  pathological  outrage,  then,  in  speaking  of 
chronic  hip-disease  as  tuberculous;  and  one  cannot  but 
admire  the  courage  with  which  Dr.  Gross  adheres  to  his 
convictions  on  this  subject.  All  men  know  that  what  this 
great  surgical  clinician  has  studied  has  been  well  studied. 

In  1877  I  presented  to  the  County  Medical  Society  of 
New  York,  a  paper,  based  on  the  analysis  of  860  cases  of 
joint  disease,  and  the  part  that  the  strumous  element  plays 
in  the  etiology  of  these  diseases  was  the  chief  point  my 
investigations  aimed  to  determine.  Much  of  that  paper  I 
shall  reproduce  in  this  connection. 

Dr.  L.  E.  Holt,  of  this  city,  has  since  been  associated 
with  me  in  the  hospital,  and  from  an  inaugural  thesis  he 
prepared  in  1880  I  have  additional  statistical  data. 

The  sexes  in  bone  lesions  of  the  hip  are  about  equally  re- 
presented. In  1818  cases  I  have  analyzed,  I  found  909 
males  and  909  females.  Dr.  Holt,  in  2307  cases  collected 
at  a  later  date  from  .the  same. hospital  records,  found  1178 
males  and  1129  females.  Those,  then,  who  argue  that 
boys  suffer  more  frequentlythan  girls  and  that  evidence  in 
favor  of  traumatism  is  therefore  furnished,  can  find  little 
to  encourage  them  in  the  statistics  I  have  adduced. 

A  word  or  two  in  reference  to  falls  and  the  influence 
they  have  on  the  minds  of  both  laymen  and  professional 
men,  may  not  be  amiss  in  this  connection.  About  the 
first  question  propounded  by  the  anxious  parent  when  a 


CHRONIC  ARTICULAR  OSTITIS :  ETIOLOGY.       2O/ 

child  with  suspected  joint-disease  is  brought  to  a  physician 
is,  "  Doctor,  do  you  think  it  came  from  a  fall  ?"  That 
question  seems  paramount  to  all  others  I  have  often 
wondered  why  the  maternal  instinct  did  not  suggest  the 
all-important  question  as  to  what  will  cure  the  child. 
Generally,  by  the  time  a  physician  has  been  consulted,  the 
history  as  to  traumatism  has  been  thoroughly  investigated 
— the  child  has  been  induced,  either  by  fear  or  by  love,  to 
admit  the  possibility  of  some  fall  on  the  sidewalk,  on  the 
ice,  or  down  a  flight  of  stairs.  If  the  unfortunate  victim 
cannot  remember  such  an  occurrence,  some  Argus-eyed 
nejghbor  calls  in  to  volunteer  testimony  on  the  subject,  so 
that  there  can  be  no  excuse  for  a  doctor  omitting  this  item 
in  getting  a  history.  I  think  it  will  be  fair  to  state  that 
most  of  the  histories,  the  data  from  which  form  the  basis  of 
this  chapter,  have  been  taken  by  men  who  have  graduated 
from  colleges  thoroughly  imbued  with  the  idea  that  trau- 
matism produced  a  very  large  proportion  of  all  the  chronic 
arthropathies. 

I  have  seen  a  great  many  paralytic  children,  have 
examined  them  with  much  care  at  various  stages  of  the 
paralysis,  and  many  have  been  under  my  observation  for 
several  years.  I  have  seen  them  fall  often,  and  frequently 
get  severe  bruises  ;  and  I  have  seen  the  injuries  neglected 
time  and  again.  No  class  of  children,  I  presume,  fall  and 
tumble  about  more  than  these  unfortunates.  To  see  an 
arthropathy  and  an  infantile  paralysis  associated  in  the 
same  patient  is  with  me  a  rarity  ;  and,  where  such  have 
been  noted,  I  have  been  particular  to  make  special  record 
of  the  case.  This  point  is  so  interesting,  that  I  have  col- 
lected a  few  figures  which  enable  me  to  speak  with  some 
degree  of  confidence.  In  the  paper,  as  read,  I  had  1440 
cases,  embracing  a  period  of  fourteen  years  ;  but,  as  I  am 
not  familiar  with  those  recorded  prior  to  1871,  I  have  con- 
cluded to  refer  only  to  those  I  have  had  an  opportunity  of 
myself  observing.  During  six  years  (1871-1877),  845  cases 
of  spinal  paralysis  in  children  under  fourteen  years  of  age 
have  been  examined  at  the  hospital,  and  of  that  number  I 
am  able  to  find  four  complicated  with  joint-disease.  In 
three  the  joint-disease  followed  the  paralysis,  in  one  it  pre- 
ceded the  paralytic  attack.  This  one  I  have  already  re- 
ported in  the  Philadelphia  Medical  Times,  for  December, 
1876. 

Age  is  a  predisposing  cause— that  is,  the  disease  occurs 


2O8  DISEASES  OF  THE  HIP. 

more  frequently  at  certain  periods  of  life — and  from  this 
fact,  arguments  are  constructed  to  militate  against  a 
strumous  diathesis  in  the  etiology.  In  560  cases  of  chronic 
ostitis  of  the  hip  analyzed  in  1880,  it  was  learned  that 
the  disease  began  before  the  fifth  year  in  352,  or  sixty- 
three  per  cent ;  290,  a  little  over  fifty  per  cent  of  all,  be- 
gan between  the  third  and  fifth  years  of  life  ;  only  39 
developed  after  the  tenth  year,  and  only  five  after  the 
thirtieth,  three  being  at  the  fourteenth,  and  one  each  at 
the  fifteenth  and  the  seventeenth  years.  Among  the  cases 
collected  were  a  number  over  ten  years,  in  which  the  prim- 
ary diagnosis  made  was  chronic  articular  ostitis,  while  the 
progress  and  result  of  many  thus  diagnosticated  revealed 
an  error,  nearly  all  proving  to  be  periarthritis,  monarticu- 
lar  rheumatism,  a  neurosis,  or  a  simple  synovitis.  The  de- 
velopment of  this  disease  after  the  fourteenth  year  of  life, 
I  feel  fully  justified,  then,  in  declaring  to  be  exceedingly 
rare.  Sixty-one,  of  the  560  analyzed,  commenced  before  the 
second  year.  It  is  most  commonly  developed,  one  can 
safely  say,  between  the  third  and  the  fifth  years.  The 
disease  is  known  to  begin  as  early  as  the  eighth  month;  but 
statistics  here  are  unreliable,  for  many  bone  diseases  at  this 
period  are  unquestionably  syphilitic. 

In  an  address  delivered  by  Dr.  S.  D.  Gross,  before  the  Amer- 
ican Medical  Association  in  1874, he  says, "It  must  be  with- 
in the  recollection  of  every  one  of  the  older  members  of  this 
association,  that  many  of  the  diseases  formerly  designated 
'  as  scrofulous  have,  (thanks  to  the  researches  of  modern 
laborers),  been  proved  beyond  the  possibility  of  doubt  or 
cavil  to  be  of  a  syphilitic  nature."  The  differential  diag- 
nosis, however,  between  syphilitic  bone  diseases  and  stru- 
mous bone  diseases  has  been  ably  set  forth  by  recent 
authors,  notably  Dr.  R.  W.  Taylor,  of  this  city.  A  study 
of  bone  syphilis  in  young  children  would  be  barren  indeed 
without  an  intimate  knowledge  of  Dr.  Taylor's  work — 
"  Syphilitic  Lesions  of  the  Osseous  System  in  Infants  and 
Young  Children."  With  the  facts  then  concerning  the  early 
age  at  which  the  upper  epiphysis  is  attacked  by  strumous 
inflammation,  it  becomes  pertinent  to  ask  why  children  in 
general  are  more  frequently  diseased  than  adults. 

For  some  valuable  information  on  this  point  I  am  in- 
debted to  Dr.  Jacobi,  who  entered  into  the  discussion 
which  followed  the  reading  of  my  paper.  He  raised  this 
very  question,  and  proceeded  to  apply  the  fact,  that  every- 


CHRONIC  ARTICULAR  OSTITIS  :  ETIOLOGY.       209 

thing  which  had  a  rapid  physiological  development  was 
apt  to  become  pathological,  to  bone  and  joint  diseases 
especially,  claiming  that  those  parts  of  a  bone  which  had 
a  rapid  circulation  of  blood  were  the  most  frequently  dis- 
eased. The  upper  portion  of  the  femur  was  better  sup- 
plied with  blood-vessels  than  the  lower  portion,  and  it  was 
a  fact  that,  when  we  had  to  deal  with  disease  of  the  bone 
in  young  children,  the  epiphysis  was  almost  always  the  seat 
of  the  inflammation.  He  referred  to  the  anatomical  fact, 
also,  that  when  man  was  born  there  was  only  a  single 
epiphysis  in  which  there  was  a  single  point  of  ossification, 
and  that  was  the  lower  epiphysis  of  the  os  femoris — all  the 
others  being  soft  tissues.  In  the  same  degree  that  the 
epiphysis  ossified,  the  doctor  continued,  the  tendency  to  in- 
flammation and  suppuration  of  the  bone  generally  would 
be  diminished.  The  remarks  of  both  Dr.  Hamilton  and 
Dr.  Jacobi  on  the  different  periods  of  life  at  which  struma 
manifests  itself,  the  different  tissues  affected,  etc.,  were 
very  interesting  and  highly  instructive.  As  I  have  not 
space  to  incorporate  the  discussion  fully  in  this  chapter,  I 
shall  refer  my  readers  to  a  verbatim  report  of  the  same  to 
be  found  in  the  Medical  Record  for  April  28, 1877. 

Without  entering  into  the  old  discussions  of  heredity  or 
transmission  of  disease  from  generation  to  generation,  I  wish 
to  affirm  my  belief  in  the  theory  that  a  disease  or  diathesis 
in  the  parent  may  be  transmitted  to  the  child,  if  not  through 
the  same  tissue  and  by  the  same  manifestations,  at  least 
through  different  tissues,  preserving  the  factors,  chronicity 
and  pertinacity. 

Let  me  illustrate.  Much  has  been  said  about  spinal 
caries  being  essentially  a  tubercular  disease,  and  men 
whose  experience  and  judgment  must  be  profoundly  re- 
spected hold  now  tenaciously  to  this  theory.  They  find 
often  a  tubercular  family  history,  probably  running 
through  two  or  three  generations;  and  where  they  do 
not  find  this  history,  they  conclude  that  such  a  diathesis 
must  exist  and  has  escaped  their  search.  The  opponents 
of  this  theory  claim  that  no  tubercular  deposit  has  been 
found  in  the  vertebrae  thus  carious,  and  furthermore,  in 
many  instances  no  tubercular  deposits  can  be  found  in  the 
lungs  or  other  organs,  and  on  these  negative  facts  they 
stoutly  deny  any  tubercular  element  in  the  etiology.  Now, 
it  seems  to  me  that  no  question  in  general  pathology  rests 
on  a  firmer  basis  than  this:  that  a  tubercular  diathesis,  or 


210  DISEASES  OF  THE  HIP. 

any  diathesis,  in  the  parent,  may  be  and  is  transmitted  to 
the  child,  manifesting  itself  not  in  the  organs  through 
which  the  diathesis  manifests  itself  in  the  parent,  but 
through  other  organs  and  tissues.  The  type  of  the  lesion 
may  change  in  many  particulars.  The  diathesis  may  be 
masked,  and  good  hygiene  and  a  prophylactic  course  of 
treatment  may  prevent  its  development  in  any  tangible 
form,  yet  there  remains  the  vulnerability.  Those  xwho 
have  had  occasion  to  study  the  alcoholic  diathesis  find 
transmitted  lesions  in  the  nervous  system.  How  fre- 
quently are  we  baffled  in  our  efforts  to  relieve  a  seemingly 
trifling  disease  in  a  child,  and  how  zealously  do  we  resort 
to  drug  after  drug,  when,  finally,  our  attention  is  called  to 
a  suspicion  of  a  syphilitic  diathesis  in  the  parents,  we  be- 
gin our  anti-syphilitic  medication,  and  a  cure  speedily 
follows!  In  one  of  the  cases  included  in  my  analysis  this 
fact  is  strikingly  illustrated: 

A  little  girl,  aged  seven  years,  was  brought  to  the  out- 
door department  for  a  synovitis  of  the  right  knee.  There 
were  found  the  usual  symptoms  and  signs  accompanying 
a  subacute  arthritis,  and,  furthermore,  the  child  seemed 
in  an  excellent  condition  of  health.  The  mother  had 
traced  the  disease  to  a  fall  some  three  months  prior  to  her 
first  visit  to  the  hospital,  which  was  during  the  early  part 
of  1876.  The  appearance  of  the  mother,  it  is  true,  aroused 
my  suspicion  as  to  the  existence  of  syphilis  in  herself,  yet  I 
could  at  that  time  see  no  connection  between  her  disease 
and  the  one  for  which  she  brought  the  child.  In  fact,  I  did 
not  pursue  an  investigation  even,  but  proceeded  to  treat  the 
child  after  the  usual  manner.  I  made  slow  progress,  and 
after  a  few  months  the  mother  grew  naturally  dissatisfied 
and  discontinued  her  visits. 

During  the  early  part  of  1877  she  returned,  after  having 
visited  in  turn  other  dispensaries.  I  found  the  child  still 
lame,  and  the  knee  in  about  the  same  condition  as  when  I 
last  saw  the  case.  I  instituted  the  same  treatment,  and 
proceeded  to  keep  full  notes  of  the  progress  of  the  case. 
After  two  months'  observation  I  found  no  improvement. 
I  then  obtained  an  accurate  history  of  the  family,  and  I 
found  that  this  child  had  been  born  subsequent  to  the  de- 
velopment of  syphilis  in  both  father  and  mother,  and  I 
obtained  a  history  of  hereditary  syphilitic  manifestations 
in  the  earlier  years  of  the  child's  life.  I  discarded  all 
former  treatment,  and  ordered  potassium  iodide,  in  ten- 


CHRONIC  ARTICULAR  OSTITIS:    ETIOLOGY.        211 

grain  doses,  thrice  daily.  Within  ten  days  the  improve- 
ment was  most  decided.  In  less  than  a  month  a  perfect 
cure  was  accomplished,  and  up  to  the  present  time  no  re- 
lapse has  occurred. 

Dr.  Taylor  has  done  more  than  any  author,  so  far  as  my 
knowledge  goes,  to  establish  the  differential  points  be- 
tween syphilitic  osseous  lesions  and  strumous  osseous 
lesions.  In  the  closing  paragraphs  of  his  excellent  work, 
to  which  allusion  has  already  been  made,  he  justly  depre- 
cates the  readiness  with  which  observers,  ordinarily  ex- 
tremely careful,  attribute  certain  swellings  about  the  dia- 
physo-epiphyseal  junction  of  the  long  bones  to  syphilis 
when  there  is  not  the  slightest  evidence  of  the  disease  in 
the  ancestors.  These  lesions  differ  in  many  characteristics 
from  those  of  syphilitic  origin.  I  can  not  do  better  than 
quote  the  following : 

"  An  important  question  here  arises,  namely  :  Are  there 
any  distinguishing  characteristics  in  these  osseous  lesions 
which  will  enable  the  physician  to  promptly  and  correctly 
diagnosticate  them  from  syphilis?  It  must  be  confessed 
that  in  the  main  they  resemble  in  many  particulars  the 
lesion  of  syphilis,  still  there  are  certain  quite  distinct  fea- 
tures which  are  important  to  know.  As  a  rule  the  osseous 
lesions  above  alluded  to  [those  of  acquired  struma]  are  de- 
veloped rather  rapidly,  maybe  complicated  early  by  degen- 
eration, and  for  the  most  part,  do  not  primarily  affect  the  joints 
[the  italics  are  my  own].  There  are  usually  a  smaller  num- 
ber of  bones  involved  than  in  syphilis,  and  there  is  a.greater 
tendency  to  unsymmetrical  development  [italics  again  my  own]. 
Pain  is  generally  a  constant  symptom,  [this  I  do  not  care 
to  italicize]  and,  in  short,  there  is  usually  a  much  more  pro- 
nounced condition  of  inflammation  than  we  find  in  syphilis. 
When  degeneration  occurs  there  may  follow  sinuses  which 
have  the  typical  scrofulous  appearance  [as  a  matter  of  course] 
which  we  have  observed  to  be  not  constant  in  syphilis.  Fi- 
nally, a  point  of  some  importance  may  be  determined  by  the 
bone  or  bones  involved;  thus,  in  this  condition, it  is  very  prob- 
able that  the  cranial  bones  would  be  unaffected,  [I  do  not 
remember  ever  to  have  seen  a  case  of  strumous  ostitis  of 
these  bones]  and  that  the  lesion  would  be  limited  generally 
to  the  long  bones,  or  perhaps  to  the  phalanges,  whereas,  in 
syphilis  we  have  found  that  a  number  of  different  classes 
of  bones  were  often  coincidently  involved.  Still,  as  I  have 
said  in  the  chapter  on  diagnosis,  the  distinction  very  often 


212  DISEASES  OF  THE  HIP. 

rests  upon  the  history  of  the  case,  and  upon  the  coexis- 
tence of  lesions  which  are  undoubtedly  syphilitic.  Treat- 
ment will  not  always  afford  conclusive  evidence,  but  it  may 
sometimes  assist  in  a  measure"  (pages  173  and  174). 

At  the  time  Dr.  Taylor  wrote  he  did  not  believe  in  the  ac- 
quired struma,  I  am  led  to  infer,  and  yet  the  etiology  of 
these  lesions  and  the  progress  correspond  identically  with 
those  of  this  diathesis. 

I  am  not,  then,  prepared  with  Dr.  Gross  to  assign  syphilis- 
so  prominent  a  place  in  the  etiology  of  a  strumous  dia- 
thesis, nor  am  I  prepared  to  speak  so  cautiously  of  it  as 
does  Dr.  Taylor.  In  my  studies  I  find  just  as  much  reason 
for  naming  this  condition  struma  as  I  do  for  naming  those 
conditions  struma  in  which  histories  of  hereditary  disease 
are  conspicuous. 

I  tabulated  two  hundred  and  sixty-five  cases  of  chronic 
ostitis  at  the  hip  with  reference  to  an  hereditary,  and  two 
hundred  and  seventy-one  with  reference  to  an  acquired  dia- 
thesis, including  the  diseases  and  conditions  which  seem  to 
develop  struma  in  a  child  even  when  the  family  record  is 
clear  of  any  transmissible  diseases  and  tendencies.  These 
I  have  found  to  be  the  exanthemata,  particularly  rubeola, 
pertussis  with  tardy  convalescence,  rachitis,  a  severe  den- 
tition, prolonged  cholera  infantum,  bad  hygiene,  etc. 

Sixty  and  one-fourth  per  cent  of  the  number  analyzed, 
from  an  hereditary  point  of  view,  gave  unmistakable  evi- 
dence of  a  diathesis  thus  transmissible,  and  evidences,  in 
other  children  of  the  family,  of  the  existence  of  such  dia- 
thesis were  found  in  twenty-five  per  cent  of  the  whole  num- 
ber. 

In  the  two  hundred  and  seventy- one  analyzed  with  refer- 
ence to  an  acquired  diathesis  eighteen  per  cent  had  de- 
veloped the  diathesis  in  this  way.  Pertutsis  stood  in  a 
causative  relationship  eight  times,  in  three  instances 
there  being  no  hereditary  influences  traceable.  Scarlatina 
seemed  to  cause  the  disease  eight  times,  there  being  no 
evidence  in  six  of  the  cases  analyzed  with  regard  to 
heredity.  In  five  cases  measles  were  the  exciting  cause, 
and  in  one  only  (four  were  analyzed)  was  there  found  any 
evidence  of  heredity. 

Since  the  publication  of  that  paper,  I  have  pursued  my 
studies  in  this  direction,  and  am  still  further  convinced  that 
not  only  do  measles  (and  whooping-cough  and  scarlatina) 
often  serve  to  bring  out  a  strumous  diathesis  in  a  child  by 


CHRONIC  ARTICULAR  OSTITIS :    ETIOLOGY.        213 

heredity  entitled  to  the  same,  but  also  induce  such  a  dia- 
thesis even  where  the  family  records  are  void  of  any  trans- 
missible diseases.  Take  the  following  case:  A  boy,  aged 
three  years,  the  picture  of  health,  and  always  regarded  as 
exceedingly  healthy.  The  parents,  both  of  whom  I  have 
the  opportunity  of  interviewing,  present  very  good  histories, 
both  personal  and  family.  The  patient,  I  find,  on  entering 
the  room,  walking  about  the  floor,  carrying  his  head  a  little 
stiffly,  the  shoulders  being  appreciably  raised.  He  will  not 
turn  the  head  without  turning  the  body  at  the  same  time. 
There  is  no  deformity  of  spinous  processes  except  a  very 
mild  degree  of  lordosis  in  mid-dorsal  region.  Notwith- 
standing the  clear  history  thus  far  obtained,  I  strongly  sus- 
pect vertebral  ostitis,  but  on  pushing  my  investigation  still 
further  I  learn  that  these  symptoms  have  not  lasted  a  week; 
that,  in  fact,  one  week  ago  he  was  very  active  and  was 
jumping  from  the  sofa,  when  he  fell,  striking  his  head  di- 
rectly against  the  floor — the  fall  producing  a  little  concus- 
sion of  the  brain,  but  that  he  rested  well  that  night  and  did 
not  manifest  any  symptoms  whatever  until  the  third  morn- 
ing, when  he  got  out  of  bed  holding  the  head  awkwardly, 
and  complaining  of  pain  on  moving  about.  Since  that 
morning  he  has  been  resting  poorly  nights,  and  his  cervical 
stiffness  has  rather  increased. 

In  view  of  this  severe  fall,  then,  with  the  above  facts  in 
view,  I  am  on  the.  point  of  excluding  any  bone  disease  in 
making  up  my  diagnosis,  and  of  attributing  the  whole  diffi- 
culty to  a  muscular  or  ligamentous  strain,  relief  from  which 
will  speedily  follow  after  rest  and  counter-irritation;  but 
on  attempting,  by  way  of  routine,  to  explore  the  posterior 
wall  of  the  pharynx  with  my  finger,  the  little  fellow  sets  up 
violent  resistance,  and  begins  coughing  rather  spasmodi- 
cally. The  father  "now  informs  me  that  he  is  just  getting 
over  whooping-cough,  which  has  already  lasted  two 
months.  With  this  additional  fact,  I  interpret  the  fall  as  a 
concussion  of  one  or  more  of  the  vertebral  bodies,  the 
nutrition  of  which  has  been  impaired  by  the  whooping- 
cough  in  such  a  way  as  to  render  them  peculiarly  vulner- 
able. This  was  a  most  unfortunate  time  for  such  a  trau- 
matism,  and  I  have  little  hesitency  in  predicting,  for  the 
little  patient  a  bone  disease  with  destructive  changes. 

In  the  Rdvue  de  Chirurgie,  No.  10,  1881,  M.  Oilier,  of  Paris, 
has  very  clearly  shown  how  such  strains  or  concussions  pro- 
duce cerebral  and  peripheral  bone  diseases,  in  an  article 


214  DISEASES   OF  THE  HIP. 

entitled  "De  1'entorse  juxta-e'piphysaire,  de  et  ses  cons6- 
quences  imme'diates  ou  61oignees  au  point  de  vue  de  1'in- 
flammation  des  os." 

In  1876  a  well-marked  case  of  articular  ostitis  of  the  hip, 
in  a  boy  aged  two  years  came  under  my  observation.  He 
was  the  second  of  two  children,  was  nursed  by  the  mother 
until  eighteen  months  old,  she  herself  having  been  unwell 
during  this  whole  period,  i.e.,  had  "  falling  of  the  womb" 
and  considerable  anxiety  on  that  account.  She  nursed  the 
first  child  two  years;  was  in  excellent  health  the  mean- 
while, and  the  child  is  reported  as  being  in  good  health. 
The  maternal  grandmother,  they  say,  died  of  consumption 
(evidence  not  very  clear)  and  with  this  exception  the  family 
history  is  believed  to  be  very  good.  The  subject  of  this 
record,  to  resume,  had  many  signs  of  rachitis  during  the 
first  year,  and  in  the  beginning  of  the  second  had  a  cholera 
infantum  which  "wore  him  away  to  a  shadow."  During 
this  illness,  without  the  probability  of  any  traumatism,  the 
mother  found  his  hip  tender  one  morning  while  changing 
the  diaper.  This  was  the  first  of  the  train  of  hip  symptoms 
which  followed. 

Last  fall,  while  seeking  diligently  in  the  presence  of  my 
class  at  the  Polyclinic  for  a  predisposing  cause  in  a  case  of 
ostitis  at  the  hip,  I  obtained  the  following  history  of  a  ro- 
bust-looking patient,  a  boy  aged  six.  He  had  a  family 
record  clear  of  any  diseases  to  which  a  diathesis  might  be 
attributed,  and  there  was  no  evidence  of  any  fall  or  injury 
of  any  kind  sustained.  In  the  summer  of  1881,  toward 
the  close  of  the  season,  he  had,  while  living  in  the  outskirts 
of  Brooklyn,  a  six- weeks'  attack  of  typho-malaria  fever  with 
a  protracted  dysentery.  The  convalescence  was  exceedingly 
tedious,  and  toward  the  close  of  this,  one  morning,  without 
any  previous  signs,  he  got  out  of  bed  a  lame  boy,  and  has 
been  lame  ever  since.  Three  months  later  he  had  a  very 
acute  exacerbation  which  lasted  only  a  week  or  two.  The 
mother  naturally  attributed  his  lameness  to  that  long  ill- 
ness, and  there  seems  to  my  mind  good  reason  for  her  belief. 

I  could  illustrate  at  great  length,  did  the  occasion  demand, 
the  influence  the  exanthemata,  and  measles  especially,  have 
in  the  production  and  the  evolution  of  a  strumous  diathe- 
sis. From  a  still  more  extended  study  on  this  subject,  I 
arrived  at  the  following  conclusions:* 

*Medical  Record,  June  3,  1882,  p.  593. 


CHRONIC  ARTICULAR  OSTITIS :   ETIOLOGY.          21$ 

I.  Measles  is  not  by  any  means  "a  trivial  disease." 

II.  Measles,  and  indeed  any  of    the  exanthemata,  with 
whooping-cough  especially  included,  are  to  be  dreaded  in 
patients  suffering  from  the  chronic  bone  and  joint  diseases 
commonly  known  as  scrofulous. 

III.  Measles  and  whooping-cough  take  precedence  among 
all  the  diseases  of  infancy  and  childhood  in  the  evolution  of 
an  hereditary  strumous  diathesis. 

IV.  A  strumous  diathesis  may  be  caused  by  an  attack  of 
measles  or  of  whooping-cough  in  a  child  whose  family  his- 
tory, both  paternal  and  maternal,  is  absolutely  free  from 
hereditary  diseases. 

A  word  regarding  histories  for  scientific  purposes.  Not 
infrequently  do  I  read  the  notes  of  a  case  published  in  the 
journals  or  the  text-books  with  which  case  I  am  perfectly  fa- 
miliar. It  is  reported  as  having  a  "  good  family  history,"  and 
to  my  certain  knowledge  there  is  enough  phthisis  and  bone 
disease  in  the  family  to  convince  the  most  skeptical.  It 
is  well  enough  to  omit  all  reference  to  a  family  history  in 
reporting  a  case,  but  to  report  the  flippant  reply  of  a  parent 
to  the  question  "  Are  you  healthy  ?"  and  "  Is  there  anything 
of  this  kind  in  your  family  ?"  as  settling  a  question  of  fact 
is  a  gross  insult  to  Science.  If  one  pretends  to  get  a  history, 
let  nothing  be  set  down  as  fact  unless  it  can  be  established 
as  fact.  Because  the  mother  is  robust-looking,  it  does  not 
follow  by  any  manner  of  means  that  her  immediate  family 
even,  is  a  healthy  one.  There  should  be  a  careful  cross- 
examination,  conducted,  however,  in  a  gentlemanly  way. 
If  it  is  incomplete,  let  the  fact  be  stated  in  the  report.  My 
faith  has  so  often  been  shaken  in  family  histories  that  I  at- 
tach no  importance  whatever  to  the  terms  "  good  "  and  "  ex- 
cellent" used  in  connection  with  the  same.  I  have  many 
letters  on  file  in  my  case-books  from  physicians  recommend- 
ing me  cases  of  joint  disease  in  which  they  state  the  family 
history  is  good,  and  in  the  same  letter  tell  about  some  other 
member  of  the  family  in  the  last  stage  of  consumption. 

One  of  the  most  rebellious  cases  of  disease  of  the  hip  I 
have  ever  had  under  my  observation,  was  in  a  girl  aged  five 
years,  who  came  under  treatment  in  1875.  Over  the  left 
sterno-mastoid  muscle  was  a  cicatrix  of  old  glandular  abscess, 
and  there  were  eczematous  excoriations  about  the  alae  nasi. 
She  had  the  typical  strumous  face,  and  while  under  treat- 
ment had  recurring  attacks  of  naso-facial  erysipelas.  The 
history  as  given  was  that  her  family  history  was  good,  and. 


2l6  DISEASES  OF  THE   HIP. 

that  the  two  other  children  were  in  fine  health.  Subse- 
quently I  learned  on  a  personal  examination  into  the  history 
that  the  father  was  consumptive  and  when  young  had  cer- 
vical abscesses;  that  the  mother  was  regarded  as  consump- 
tive (since  died  of  this  disease),  had  had  several  still  births, 
and  came  herself  of  a  family  in  which  struma  and  tubercu- 
losis prevailed.  She  had  a  brother  who  had  multiple  cold 
abscesses  when  six  years  of  age,  continuing  more  or  less  up 
to  the  time  of  his  death  by  consumption,  at  the  age  of  nine- 
teen years.  I  learned,  furthermore,  that  the  eldest  child  in 
the  family  was  delicate  as  a  baby,  suffering  much  from  ab- 
scesses about  the  thigh;  and  that  the  patient  herself  had 
when  young  chronic  eczema-capitis  with  cervical  adenitis. 

The  proneness  in  certain  individuals  to  the  development 
of  multiple  bone  lesion  in  close  proximity  to  articular 
surfaces  is  one  of  the  strongest  arguments,  I  think,  that  can 
be  adduced  in  favor  of  a  strumous  diathesis.  I  have 
seen  many  cases  where  only  one  hip  was  involved  develop 
a  similar  lesion  in  the  other  hip  while  under  treatment; 
and  by  treatment  I  mean  both  the  expectant,  so-called,  and 
the  best  form  of  mechanical.  To  find  a  case  of  caries  of  the 
vertebrae  with  caseous  ostitis  of  the  hip  and  of  the  ankle  is 
not  an  uncommon  occurence. 

In  1875  I  presented  to  the  New  York  Pathological  Society 
a  specimen  of  caseous  ostitis  of  the  head  of  the  femur 
where  multiple  abscess  of  the  lungs  had  followed.  The 
patient  had  also  caries  of  the  ankle.  The  boy  was  seven 
years  of  age,  was  the  second  of  three  children,  all  of  whom 
were  in  a  state  of  health  far  below  the  normal  standard. 
His  father  died  at  the  age  of  thirty-six  of  phthisis  pul- 
monalis,  six  months  after  a  form  of  insanity  for  which  he 
was  confined  in  the  Flatbush  Asylum.  Both  the  insanity 
and  the  phthisis,  it  is  fair  to  say,  were  developed  two  years 
subsequent  to  the  birth  of  this  child.  A  paternal  aunt 
died  of  phthisis.  The  mother  had  been  choreic  from  girl- 
hood. His  maternal  grandfather  died  in  an  insane  asylum. 
A  maternal  aunt  was  insane  at  the  time  I  made  my  report. 

With  the  exception  of  a  slight  herpectic  eruption  about 
the  nasal  orifice,  the  child  was  considered  healthy  up  to 
his  third  summer,  when  a  colliquative  diarrhoea  set  in,  and 
for  months  following  this  a  peculiar  ackwardness  in  his 
gait  was  noticed.  Finally  he  recovered  completely,  so 
report  went,  and  during  the  summer  of  1872,  when  only 
four  years  of  age,  he  fell  from  a  railing,  and  on  the  next  day 


CHRONIC  ARTICULAR  OSTITIS:  ETIOLOGY.          217 

•complained  of  a  pain  in  the  left  knee.  This  pain  soon  sub- 
sided, and  nothing  save  a  slight  limp  on  extra  exertion  was 
observed  for  the  next  six  months.  Then  "the  starting 
pains,"  the  gradual  change  in  the  position  of  the  limb,  and 
tenderness,  induced  the  mother  to  seek  medical  advice. 
An  abscess  formed  five  months  later. 

In  March,  1874,  the  right  ankle  quite  suddenly,  and 
without  apparent  cause,  took  on  severe  inflammation. 
Other  abscesses  formed,  but  shortly  after  the  invasion  of 
the  ankle,  the  scarlatina  was  contracted,  and  this  was  fol- 
lowed by  oedema  of  the  lower  extremities,  and  chorea  fol- 
lowed also  in  the  wake  of  the  scarlatina.  For  a  full  report 
of  this  case  see  Trans.  Path.  Soc.,  vol.  i.,  p.  72. 

Many  instances,  I  know,  can  be  found  where  a  diathesis 
seems  to  be  wanting  when  the  case  first  comes  under 
observation,  and  I  have  recorded  many  myself,  but  during 
the  progress  of  the  case  other  manifestations,  notably 
strumous,  will  appear,  and  facts  in  connection  with  the 
family  history  will  be  brought  out  that  can  not  be  contro- 
verted. Time  and  again  I  have  had  this  experience,  and 
hence  my  convictions  about  the  relationship  of  this 
diathesis  to  the  bone  disease  of  which  I  am  treating  have 
been  forced  upon  me,  nolens  volens. 

Traumatism  may  and  often  does  play  an  important  part 
as  an  exciting  cause,  yet  one  would  marvel  why  grave 
lesions  do  not  follow  the  numerous  cases  of  strains  and  con- 
tusions about  the  hip — many  of  them  were  of  the  most  severe 
character  and  many  very  trival — that  appear  at  the  out-door 
department  of  the  hospital  with  which  I  am  connected.  Let 
me  give  an  extract  from  a  lecture  in  Seguins'  Clinical  Series, 
1877,  of  a  gentlemen  who  has  had  very  large  experience  in 
these  diseases,  and  one  who  has  the  reputation  of  being  a 
careful  observer.  Dr.  Newton  M.  Shaffer  says: 

"  Experience  proves  that  traumatism  excites  acute  lesions 
only,  as  a  rule.  In  those  constitutions  strong  enough  to 
resist  and  repair  the  injury  these  acute  troubles  soon  sub- 
side: under  reverse  circumstances  they  are  apt  to  be  followed 
by  a  chronic  form  of  inflammation  which  may  end  in  sup- 
puration. .  .  .  Traumatic  joint  lesions  (excluding  incised 
wounds  of  the  capsule)  are  not  very  frequently  seen,  unless 
we  accept  sprain  and  dislocation  as  being  lesions  of  this 
character.  When,  however,  these  typical  traumatic  joint 
lesions  occur,  they  present  symptoms  that  are  unmistak- 
able. They  no  more  resemble  the  ordinary  forms  of 


2l8  DISEASES  OF  THE  HIP. 

chronic  joint  disease  in  their  course  and  history  than  a 
fracture  resembles  a  chronic  ostitis." 

In  this  same  lecture  there  occurs  a  very  instructive  case 
in  a  boy,  aged  five  years,  of  dislocation  of  the  hip,  which 
was  reduced  by  Dr.  Little  fourteen  days  after  the  accident, 
and  for  ten  days  following  this  reduction  the  boy  presented 
symptoms  that  some  regard  as  diagnostic  of  chronic  joint 
disease.  Dr.  Shaffer  very  clearly  set  forth  the  difference, 
however,  and  the  subsequent  history  of  the  case  was  a 
gradual  subsidence  of  all  symptoms  and  a  complete  re- 
covery. The  patient  had  a  typical  strumous  history  too, 
and  was  five  years  of  age,  so  that  here  there  was  sufficient 
trauma  of  not  only  the  ligamentum  teres,  but  the  capsular 
also,  to  induce  a  chronic  "hip  disease." 

I  have  myself  placed  on  record  in  the  American  Journal 
of  the  Medical  Sciences,  1869,  a  case  of  traumatic  disloca- 
tion in  a  child,  aged  four  years,  in  which  I  reduced  the 
dislocation  at  the  end  of  six  weeks.  There  was  perfect 
restoration.  The  efforts  at  reduction  were  very  great,  as 
will  be  seen  by  the  subjoined  notes. 

One  evening  of  June,  1878,  I  had  my  frienti,  Dr.  Ripley, 
see  the  patient  with  me.  He  fully  confirmed  the  diagnosis 
I  had  already  made,  and  we  proceeded  at  once  to  reduce 
the  dislocation.  Chloroform  was  administered  and  when 
anaesthesia  was  complete  the  limb  was  rotated,  while  the 
thumb  and  fingers  grasped  the  head  of  the  thigh  bone, 
which  could  be  felt  to  roll  distinctly.  The  Doctor  made 
out  the  same  shortening  that  I  had  made  'but  some  days 
previously.  With  the  aid  of  a  towel  one  held  the  pelvis  quite 
securely,  whiJe  the  other  manipulated  the  limb.  We  flexed 
the  thigh  acutely  on  abdomen,  rotated  inward,  then  ex- 
tended. This  was  no  avail.  We  then  flexed  and  abducted 
and  extended,  and  the  deformity  remained  the  same. 
Every  possible  manoeuvre  was  resorted  to,  and  for  fully 
one  hour  we  worked  without  any  success  whatever. 
Finally,  after  a  strong  adduction  and  careful  extension, 
the  bone  could  be  felt  under  one's  fingers  to  slip  into 
place.  There  was  no  noise  made,  and  we  were  only 
assured  of  our  final  success  by  finding  the  limbs  parallel, 
equal  in  length,  and  the  movements  at  the  joint  normal. 
A  double  spica  bandage  was  applied,  the  limbs  bandaged 
together,  straight  splints  having  been  bound  in  popliteal 
space,  and  a  pad  having  been  placed  between  the  knees. 
An  opiate  was  ordered  for  the  night. 


CHRONIC  ARTICULAR  OSTITIS :   ETIOLOGY.       219 

On  the  second  day  I  find  child  free  from  pain,  and  the 
mother  reports  that  after  the  first  night  he  rested  very  well. 
The  bandages  are  removed  to-day  and  the  limbs  remain 
quite  straight;  passive  motion  made  with  comparative  ease 
and  the  dressings  re-applied.  An  enema  is  ordered. 

Five  days  later  the  mother  brings  the  child  to  the  dispen- 
sary and  reports  that  he  has  rested  well  and  been  free  from 
pain  since  I  saw  him  last.  The  limbs  are  of  equal  length,  and 
both  lie  straight  and  parallel,  one  with  the  other.  There 
is  a  moderate  degree  of  resistance  to  complete  extension, 
flexion,  and  adduction,  though  the  thigh  can  be  moved  in 
flexion  over  an  arc  of  about  90°  with  ease,  and  rotation  can 
be  made  with  the  same  degree  of  facility.  Only  a  spica 
is  worn  at  present. 

He  continued  to  improve,  occasionally  having  a  "catch- 
ing pain"  as  he  walked. 

Three  weeks  after  the  reduction  flexion  could  be  made 
over  the  normal  arc;  rotation  not  quite  perfect,  and  a  very 
slight  halt  was  observable. 

At  the  end  of  a  month  he  walked  and  ran  quite  freely, 
and  I  could  not  detect  any  halt  in  his  gait.  The  mother 
said  she  could  not  tell  by  his  walking  which  was  the  lame 
limb.  Flexion  and  extension  perfect  and  painless;  rotation 
nearly  so;  a  scarcely  appreciable  change  in  the  nates;  no 
atrophy;  no  shortening;  geneal  health  good. 

In  tracing  out  some  cases  in  January,  1879,  I  called  at 
the  residence  of  this  patient  and  found  that  he  had  been 
free  from  any  pain  or  lameness  since  the  date  of  his  last  visit. 
I  had  him  stripped,  and  on  a  thorough  examination  I  could 
find  no  symptom  or  sign  of  disease  about  the  joint.  His 
rotation  was  perfect. 

If  this  injury  were  not  severe  enough  to  induce  an  arthritis, 
then  it  is  useless  to  talk  of  falls  as  "causing  hip  disease." 
It  is  fair  to  assume  that  the  ligamentum  teres  was  either  torn 
across  or  severely  stretched,  and  we  must  admit  a  certain 
amount  of  injury  done  the  capsular  ligament.  Then,  too, 
the  bruising  and  pulling  and  tortion  that  were  incidental  to 
the  efforts  at  reduction  were  certainly  sufficient  to  cause 
disease  in  the  joint,  even  if  it  had  already  escaped  per- 
manent injury.  Dr.  Sayre,  on  page  237  of  his  Lectures,  says: 

"  A  pinch  of  the  skin,  producing  a  '  blood  blister,'  or 
slight  extravasation  of  blood  within  the  cellular  tissue,  is 
of  common  occurrence,  and  is  of  no  great  importance.  If 
let  alone  it  will  soon  be  absorbed  ;  or  at  most  if  you  let  the 


22O  DISEASES  OF  THE   HIP. 

fluid  Out  and  do  not  irritate  the  wound,  it  will  soon  get 
well.  But  suppose,  even  in  this  most  trifling  injury,  that 
instead  of  giving  it  rest  and  time  to  heal  you  constantly 
scratch  it  with  a  rusty  nail  ;  you  will  produce  a  sore  that 
will  last  as  long  as  the  irritation  is  continued.  [My  patient 
walked  around  six  weeks  irritating  those  joint  structures, 
and  they  got  no  rest.]  This  is  a  parallel  case  with  a  joint 
that  is  exercised  after  concussion,  or  a  blow  or  wrench  that 
has  produced  an  extravasation  of  blood  from  tufts  of 
blood-vessels  already  referred  to*" 

Dr.  Shaffer,  in  his  lecture,  says  :  "  If  we  take,  for  ex- 
ample, a  case  of  chronic  joint  disease  at  the  earliest  mani- 
festations of  the  local  symptoms,  and  treat  it  locally,  as  we 
would  a  fracture  or  a  dislocation,  can  we  assure  ourselves 
that  we  will  arrest  the  disease  ?  Can  we  feel  certain  that 
pus  will  not  form  ?  I  do  not  mean  to  disparage  local  treat- 
ment in  joint  disease  when  I  say  that  we  cannot." 

This  leads  to  the  question: 

Can  Joint- Disease  occur  in  a  Non-strumous  Child  ? — At  the 
meeting  of  the  New  York  County  Medical  Society,  in 
March,  1877,  in  the  discussion  which  followed  the  reading 
of  my  paper,  Dr.  Sayre  propounded  the  above  question,  or 
what  I  take  to  be  its  equivalent,  viz.:  "  Can  Pott's  disease 
of  the  spine,  or  hip-joint  disease,  develop  from  an  injury  in 
a  child  in  perfect  health  and  absolutely  free  from  any  here- 
ditary diathesis  ?"  The  question  was  propounded  for  Dr. 
Frank  Hamilton,  who  had  just  spoken,  or  myself,  to  answer. 
Dr.  Hamilton  answered  in  the  affirmative.  A  remark  of 
no  less  a  distinguished  surgeon  than  Prof.  S.  D.  Gross  was 
given  by  Dr.  Sayre,  which  was  that  hip-joint  disease  could 
not  occur  in  any  man,  woman,  or  child,  unless  a  tuberculous 
diathesis  be  present.  Such  a  statement,  I  confess,  caused 
some  surprise,  and  induced  me  to  conduct  a  more  thorough 
analysis  of  such  cases  as  I  had  hastily  recorded  in  my 
paper,  then  incomplete,  wherein  "nothing  found"  was 
specified. 

Of  596  cases  analyzed  with  reference  to  hereditary,  and  614 
with  reference  to  an  acquired,  diathesis,  I  have  succeeded  in 
finding  only  one  case  of  which  it  can  be  surely  said  there  was 
no  struma  complicating.  The  three  cases  of  spinal  disease 
which  I  had  reported  in  my  paper  may  be  classed  by  some 
as  non-strumous,  but  I  feel  sure  others  will  differ  in  their 
opinion. 

I  think  I  am  prepared  to  answer  the  question  now,  as 


CHRONIC  ARTICULAR  OSTITIS  :    ETIOLOGY.        221 

propounded  by  Dr.  Sayre.  Whatever  other  observers  may 
have  experienced,  I  feel  warranted  in  stating,  from  a  careful 
study  of  the  cases  whose  analysis  is  here  recorded,  that 
true  chronic  joint-disease  cannot  occur  in  a  non-strumous 
child.  I  believe  that  a  slight  injury  often  develops  or  acts 
as  exciting  cause,  but  never  in'duces  the  disease  unless  a 
predisposing  cause  be  present.  I  am  not  prepared  with  Prof. 
Gross,  to  admit  that  that  predisposing  cause  is  always  a 
transmitted  tubercular  diathesis;  but  lam  firmly  convinced 
that  it  lies  in  a  morbid  condition,  which  is  either  hereditary 
and  permanent,  or  acquired,  whether  temporary  or  per- 
manent. 

Are  Chronic  Joint-Diseases  ever  the  Cause  of  the  Strumous 
Diathesis'? — Mr.  T.  Holmes,  in  his  "Surgical  Treatment  of 
Children's  Diseases,"  on  pages  337,  338,  after  speaking  of 
the  causes  of  struma,  makes  the  following  observation: 

"  I  believe,  also,  that  protracted  suppuration  is  an  efficient 
cause  of  tuberculosis,  and  that  many  of  the  exhausting  joint- 
diseases  which  prove  fatal  ultimately  by  phthisis,  and  are 
therefore  set  down  as  strumous,  were  really  themselves  the 
cause,  and  not  the  effect,  of  the  tuberculous  diathesis." 
From  a  careful  reading  of  Mr.  Holmes's  remarks  on  struma, 
I  came  to  the  conclusion  that  he  made  only  a  difference  in 
degree  between  the  strumous  and  the  tuberculous  diathesis. 

That  a  joint-disease  long  continuing  does  sometimes 
develop  struma  in  a  child  already  predisposed,  I  have  not 
the  slightest  doubt ;  but  that  it  causes  the  diathesis  de  novo, 
as  scarlatina  causes  it,  or  as  rubeola  or  pertussis  causes  it, 
I  entertain  grave  doubts.  As  bearing  on  the  question,  I 
have  selected  such  cases  as  have  been  under  observation 
during  a  period  varying  between  six  months  and  six  years, 
and  have  analyzed  them  closely,  including  in  my  table  those 
wherein  amyloid  degeneration  developed,  wherein  adenia, 
tuberculous  meningitis,  recurring  naso-facial  erysipelas, 
chronic  recurring  phlyctenular  conjunctivitis,  diseases  of 
other  joints  and  of  the  bones,  and  several  types  of  vaccinia 
occurred. 

Three  hundred  and  twenty  cases  were  found  for  observa- 
tion, and  of  this  number  two  hundred  and  thirty-six  gave 
no  evidence  of  strumous  disease  in  any  other  locality. 
Manifestations  undoubtedly  strumous  were  observed  in 
eighty-two,  while  in  fifty-two  of  the  two  hundred  and 
thirty-six  there  was  exhaustion  in  its  various  degrees. 
Before  giving  the  different  types  of  struma  as  developed 


222  DISEASES  OF  THE  HIP. 

while  the  patients  were  under  observation,  I  propose  to 
show  what  number  of  those  wherein  exhaustion  was  a 
prominent  feature  actually  developed  any  strumous  signs 
in  localities  or  tissues  other  than"  the  joints  ;  also  to  show 
whether  such  developments  were  due  to  the  exhaustion,  or 
to  other  well-known  causes  or  conditions,  which  were  pres- 
ent, and  which  were  noted  in  the  histories. 

Those  fifty-two  cases,  I  may  as  well  state,  were  cases  in 
which  long-continued  suppuration  existed,  and  in  which 
exhaustion  pure  and  simple  was  the  only  sign  noticed. 
Seventeen  of  these  were  in  the  hospital  from  six  to  twelve 
months,  and  fifteen  I  saw  twice  a  day  during  the  whole  of 
their  hospital  sojourn  ;  twenty-one  were  in  the  hospital 
from  one  to  two  years,  and  all  of  them,  likewise,  I  saw 
twice  a  day.  Eight  were  under  the  same  daily  observation 
for  periods  ranging  between  two  and  three  years.  The 
remaining  six  were  under  observation  from  four  to  five 
years,  one  as  an  out-patient,  the  others  as  in-patients.  I  am 
thus  specific  lest  some  one  may  say  that  strumous  mani- 
festations may  have  appeared,  and  soon  disappeared,  no 
note  having  been  made.  I  have  kept  faithful  records  of  the 
cases,  and  such  can  be  found  at  any  time  on  the  hospital 
case-books.  Furthermore,  twenty-three  of  the  fifty-two 
died  from  exhaustion  induced  by  the  long  suppuration,  and 
no  struma  in  other  localities  occurred.  I  can  with  assur- 
ance, then,  state  that  in  fifty-two  cases  of  suppurating 
joint-disease  this  diathesis  was  not  manifest  extrarthritic. 

A  further  analysis  of  the  fifty-two  cases  of  exhaustion 
gives  the  following  result:  In  sixteen  no  attempt  was  made 
by  the  historian  to  trace  any  hereditary  diseases  in  either 
member  of  the  family,  or  the  connection  of  any  of  the  dis- 
eases of  infancy  with  the  joint  disease  ;  in  thirty-six,  a  pre- 
disposing cause  was  found  either  in  a  transmitted  or  an 
acquired  diathesis,  or  in  both.  Twenty-seven  gave  heredi- 
tary diseases  in  the  parents,  and  evidence  of  acquired 
struma  was  found  in  twenty-five.  The  hereditary  diseases 
were  found  more  frequently  in  the  father  than  in  the 
mother  ki  the  proportion  of  about  two  to  one.  Evidences 
of  strumous  disease  were  found  in  other  members  of  the 
family  in  fourteen  instances.  In  every  case,  then,  exclusive 
of  the  sixteen  in  which  no  attempt  was  made  to  ascertain 
the  existence  of  a  possible  predisposition,  a  cause,  in  a 
greater  or  less  degree  adequate,  was  found  for  the  severity 
of  the  disease  ;  in  other  words,  a  strumous  diathesis,  either 


CHRONIC  ARTICULAR  OSTITIS :    ETIOLOGY. 

hereditary  or  acquired,  could  with  reasonableness  be  pre- 
dicted of  every  case. 

Of  the  eighteen  cases  affected  with  strumous  disease  of 
the  lymphatic  ganglia,  such  as  I  have  classed  as  adenia,  only 
one  suffered  from  any  exhaustion  consequent  on  suppura- 
tion prior  to  the  glandular  infiltration.  In  the  thirteen 
cases  with  recurring  nasal  and  fascial  erysipelas  as  the  ex- 
ponent of  the  strumous  diathesis,  there  was  no  suppuration 
in  nine  ;  the  suppuration  was  very  slight  and  not  at  all  ex- 
haustive in  two,  while  in  two  there  was  prolonged  sup- 
puration antedating  the  first  appearance  of  the  lesion  under 
consideration,  and  in  both  of  these  two  the  family  histories 
were  sufficiently  poor  to  account  for  a  transmitted  tubercular 
diathesis.  Consumption  was  found  on  both  sides,  and  an 
exanthem  as  an  exciting  cause  of  the  joint  disease  in  one  ; 
while  in  the  other  the  mother's  family  was  decidedly  con- 
sumptive, and  an  acute  necrosis  in  three  or  four  different 
localities  was  the  exciting  cause  of  the  joint  disease. 

There  was  no  suppuration  in  five  cases  dying  of  tuber- 
cular meningitis,  but  there  was  some  excitement  from  the 
pain  incident  to  the  disease  of  the  joint  in  four  of  this 
number,  while  in  one  there  was  no  severe  pain  at  any  time. 
In  five,  long-continued  suppuration  produced  exhaustion, 
which  was  thought  to  have  been  the  cause  of  the  menin- 
geal  disease;  but  in  one  of  the  five  pertussis,  severe  in 
character,  occurred  just  prior  to  the  prodromal  period  of 
the  fatal  tubercular  meningitis,  and  could  with  propriety 
have  been  considered  the  cause. 

Among  the  cases  in  which  strumous  disease  developed 
as  chronic  and  recurring  phlyctenular  conjunctivitis,  four 
occurred  prior  to  any  suppuration,  and  in  three  there  was 
no  suppuration  while  under  observation.  Of  the  three 
who  suffered  from  an  unnecessarily  severe  and  chronic 
vaccinia,  two  had  been  the  subjects  of  suppurative  disease 
of  the  joints,  while  one  of  these  even  bore  marks  of  struma 
about  the  cervical  region  and  in  the  eyes,  reported  to  have 
antedated  the  suppuration,  and  in  the  other  consumption 
was  foun*d  on  the  mother's  side,  rheumatism  (chronic  artic- 
ular) on  the  father's. 

Of  the  whole  number  of  the  cases  of  amyloid  degenera- 
tion twenty-two  suffered  a  more  or  less  degree  of  exhaustion 
from  prolonged  suppuration. 

To  resume,  then.  Of  the  number  analyzed  with  refer- 
ence to  the  question  of  exhaustion  from  prolonged  suppur- 


224  DISEASES   OF  THE  HIP. 

ation  causing  the  strumous  diathesis,  eighty-four  were  found 
to  have  been  the  subjects  of  exhaustion  in  various  degrees  of 
severity.  In  fifty-two  no  strumous  manifestations  in  other 
portions  of  the  body  than  the  joint  thus  affected  occurred 
during  the  period  of  observation;  in  nine  there  was  stru- 
mous disease  elsewhere  manifest,  but  the  facts  go  to 
show  that  the  predisposition  existed  prior  to  the  suppura- 
tion and  exhaustion,  and  had  actually  shown  itself  in  some 
instances,  hence  the  disease,  or  diathesis,  was  simply  de- 
veloped, and  not  caused  de  noz'o,  by  the  exhaustion. 

In  the  twenty-two  cases  of  amyloid  degeneration  of  the 
liver  and  kidneys,  exhaustion  was  the  exciting  cause  in 
every  one;  but  from  the  table  it  will  be  seen  that  in  nine- 
teen out  of  the  twenty-two  an  efficient  predisposing  cause 
was  found,  while  in  the  remaining  three  no  such  predispos- 
ing cause  was  sought.  If  amyloid  disease  be  strumous,  it 
may  be  interesting  to  know  why  this  peculiar  type  of  stru- 
ma  should  occur — what  factors  are  necessary  to  its  pro- 
duction. I  have  often  wondered  why  some  cases  of  joint- 
disease  could  suppurate  profusely  for  months,  and  for  years 
even,  and  no  amyloid  changes  in  liver  and  kidneys  occur. 
We  have  only  twenty-two  of  the  eighty-four  cases  of  ex- 
haustion, or  about  twenty-seven  per  cent,  terminating  in 
this  lesion;  and  the  suppuration  in  the  twenty-two  was  not 
greater,  and  did  not  extend  over  a  longer  period,  than  that 
of  the  fifty-two  of  uncomplicated  exhaustion. 

It  is  a  significant  fact,  that  in  every  case  of  amyloid 
disease  where  a  family  history  was  sought  —  twelve  in 
number — an  hereditary  disease  was  found;  and  this  heredi- 
tary disease — a  fact  still  more  significant — was  found  to 
be  pulmonary  consumption  in  ten  out  of  the  twelve. 
The  consumption  was  in  the  father  in  five  instances,  in 
the  mother  in  six,  being  found  in  both  father  and  mother 
once.  One  history  of  the  two  remaining  gave  chronic 
rheumatism  in  the  father  and  in  the  mother,  while  stru- 
mous diseases  were  found  in  other  members  of  the  family; 
the  other  gave  habitual  drunkenness  in  the  father,  and 
probable  consumption  in  the  mother,  a  wretched  hygiene 
being  found  as  an  element  of  no  little  importance.  In 
seven  no  family  history  was  obtained,  but  the  personal 
history  gave  an  exanthem  as  causing  or  developing  a  stru- 
mous diathesis,  associated  with  a  bad  hygiene  in  two,  un- 
associated  with  a  bad  hygiene  in  one.  Bad  hygiene  was 
found  to  have  existed  in  a  highly  probable  causative  rela- 


CHRONIC  ARTICULAR  OSTITIS  :   ETIOLOGY.         22$ 

tionship  to  the  joint-disease,  and  its  severity,  in  five  cases, 
one  of  which  was  furnished  with  additional  evidence  of 
struma,  by  the  existence  of  such  diseases  in  other  members 
of  the  family.  In  no  one  of  these  cases  was  even  a  per- 
sonal history  obtained.  Hence  the  data,  for  conclusions 
are  very  imperfect  so  far  as  the  last  five  are  concerned,  in 
fact,  the  whole  ten,  where  no  family  history  was  obtained, 
are  valuable  only  so  far  as  their  harmlessness  to  a  theory 
is  concerned.  Amyloid  changes  have  been  observed  in  the 
glandular  tissues  almost  exclusively.  The  theory  to  which 
I  have  referred  is,  "The  lymphatic  diathesis  is  in  most 
cases  congenital,  and  transmitted  from  generation  to  gen- 
eretion." 

I  believe  that,  if  Billroth  had  asserted  that  such  was  the 
fact  in  every  case,  his  assertion  could  not  have  been  dis- 
proved. 

The  question,  then,  raised  at  the  beginning  of  this  branch 
of  my  subject,  "Are  chronic  joint-diseases  ever  the  cause  of 
the  strumous  diathesis?"  cannot  be  answered  affirmatively 
by  the  history  of  any  one  of  the  three  hundred  and  twenty 
cases  I  have  had  under  observation.  That  chronic  joint- 
diseases  sometimes  develop  strumous  disease  in  other  lo- 
calities in  an  individual  in  whom  a  predisposition  already 
exists,  twenty-two  of  my  cases  abundantly  prove.  Yet,  as 
my  analysis  furnishes  proof  incontestable  that  the  joint- 
disease  itself  is  strumous,  it  remains  for  other  investigators 
to  prove  that  chronic  joint-diseases,  by  any  amount  of  sup- 
puration, ever  develop  even,  a  strumous  diathesis.  /  cannot 
frovc  the  assertion. 

The  conclusions,  then,  to  be  drawn  from  these  extended 
remarks  and  statistics  are  that: 

1.  A  strumous  diathesis,  either  hereditary  or  acquired,  is 
the  great  predisposing  cause  of  all  chronic  inflammatory 
ibone  lesions  of  the  hip. 

2.  That  the  disease  may  be  excited  by  a  fall  or  strain  or 
wrench,  exposure  to  cold,  or  by  an  acute  disease,  an  exan- 
.them,  for  instance,  with  a  prolonged  convalescence. 

3.  That  in  many  cases  no  exciting  cause  can  be  found. 
All  this  question  of  etiology,  then,  must  have  some  prac^ 

tical  bearing.  The  successful  treatment  of  these  maladies, 
attended  with  so  much  suffering,  productive  of  so  much 
deformity,  much  of  which  is  often  irremediable,  and  the 
•mortality — a  lingering  mortality,  too — of  which  is  between 
ten  and  twelve  per  cent — the  successful  treatment,  I  say,  is 


226  DISEASES  OF  THE  HIP. 

the  prize  to  the  attainment  of  which  all  our  labors  should 
tend.  That  many  diseases  essentially  constitutional  de- 
mand local  treatment,  no  sane  man  will  deny;  and,  with  a 
proper  understanding  of  the  constitutional  vice  on  which 
the  local  lesion  depends  for  its  existence,  no  sane  man  will 
assert  that  local  treatment  alone  will  meet  all  the  indica- 
tions. 


CHAPTER  XIII. 

CHRONIC  ARTICULAR  OSTITIS  OF  THE  HIP. 
CLINICAL  HISTORY  AND  COMPLICATIONS. 

The  nature  of  diseases  that  are  chronic  and  marked  by 
exacerbations  is  usually  not  duly  appreciated,  and  this 
lack  of  appreciation  renders  both  therapeutics  and  prog- 
nosis inexact  and  unreliable. 

In  lecturing  on  this  disease  I  have  heard  it  reported  that 
an  old  professor,  a  pioneer  in  orthopedic  surgery,  was  wont 
to  say,  that  any  one  could  get  a  reputation  in  the  treatment 
of  hip-disease  provided  the  case  was  secured  near  the 
close  of  an  exacerbation.  He  advised  then  that  the  patient 
be  dismissed  as  soon  as  the  temporary  relief  followed. 

To  estimate  the  value  of  any  plan  of  treatment  in  any 
given  disease  one  must  know  the  natural  history  of  the 
disease  itself. 

The  division  of  this  malady  into  stages,  while  it  may  ex- 
press an  incorrect  idea  of  the  pathology,  is  very  desirable; 
I  shall  hence  retain  the  old  nomenclature.  By  the  first  is 
meant  the  early  stage,  and  it  means  to  my  mind  the  stage 
of  ostitis.  The  symptoms  are  not  always  the  same,  yet  the 
signs  are  quite  uniform.  When  a  case  presents  a  lameness 
which  points  to  a  saving  of  the  hip,  however  slight,  a  flatten- 
ing of  the  nates  and  a  resistance  to  passive  movements, 
with  the  minimum  amount  of  deformity,  we  call  this  the 
first  stage,  i.e.,  so  far  as  signs  go.  The  symptoms  may  be 
only  an  occasional  pain  when  active  or  passive  motion  is 
made,  or  the  most  violent  pain  even  when  the  limb  is  at 
rest.  Again,  there  may  not  be  a  symptom  present  and  the 
deformity  may  be  scarcely  appreciable.  If  we  limit,  then, 
this  stage  to  the  period  between  the  initial  lameness  and  the 
establishment  of  deformity  irrespective  of  the  length  of 
the  interval,  one  can  understand  always  what  we  mean  when 
speaking  of  the  early,  or,  first  stage. 

It  will  fairly  indicate,  too,  the  first  stage  in  the  patho- 


228  DISEASES  OF  THE  HIP. 

logical  process.  Marked  deformity  rarely  accompanies  a 
pure  ostitis  of  the  diaphyso-epiphysial  centres  of  develop- 
ment. So  long  as  the  inflammatory  process  does  not  ex- 
tend by  contiguity  or  by  actual  rupture  into  the  synovial 
cavity,  the  symptoms  and  the  signs  are  not  apt  to  be  other 
than  reflex.  These  may  continue  for  months,  scarcely 
appreciable.  At  present  we  have  in  the  hospital  two  cases 
of  chronic  bone  disease  in  the  neighborhood  of  the  articu- 
lar surfaces  of  the  knee-joint,  and  the  present  theory  as 
to  the  pathogeny  of  chronic  epiphysitis  is  most  beautifully 
demonstrated.  At  times  the  patients  walk  with  a  limp  that 
can  be  detected  only  by  the  most  careful  observer,  and  the 
functions  of  the  joints  seem  perfect  when  the  knee  is  flexed  ; 
the  contour  of  the  parts  notably  differs  from  the  normal, 
and  yet  while  extended  the  difference  cannot  be  readily 
appreciated.  On  palpation  the  extra  heat,  and  the  bony 
enlargment  can  be  easily  recognized. 

Then,  again,  acute  symptoms  suddenly  appear  on  trivial 
provocations,  lameness  is  extreme,  and  the  signs  of  a  dis- 
tended synovial  sac  are  very  marked,  palpation  detecting 
the  fluid  without  any  doubt.  A  few  days'  rest  seem  to  allay 
these  acute  symptoms,  and  the  parts  relapse  again  to  the 
nearly  normal  condition.  Such  has  been  the  course  of  events 
in  these  two  cases  for  nearly  a  year,  and  the  explanation  is 
this  :  the  inflammation  extends  occasionally  to  the  articu- 
lar surface,  rapidly  spreading  to  the  whole  synovial  mem- 
brane and  a  serous  synovitis  results.  This  soon  subsides, 
there  being  no  purulent  element,  and  the  bone  lesion 
slowly  progresses,  as  before. 

Now,  nothing  seems  clearer  to  my  mind  than  the  identity 
between  these  processes  and  those  going  on  in  the  vicinity 
of  the  hip. 

It  is  a  significant  clinical  fact  that  tissues  once  inflamed 
are  rendered  the  more  vulnerable,  and  recurring  attacks 
making  successive  inroads  finally  induce  destructive  changes. 

The  main  point,  however,  I  am  endeavoring  to  make  is 
this,  viz.,  that  the  first  stage  of -chronic  articular  ostitis  has  a 
symptomatology  that  is,  like  the  pathological  process,  sub- 
ject to  changes.  When  a  synovitis  by  contiguity  makes 
its  appearance,  the  symptoms  and  signs  become  those  of  a 
synovitis,  and  one  examining  the  hip  at  this  juncture  would 
find  the  sign  of  the  second  stage.  So  long  as  the  synovitis 
is  not  fungous  or  purulent,  resolution  takes  place  and 
then  we  have  the  clinical  features  of  the  first  stage. 


CHRONIC  ARTICULAR  OSTITIS :   SYMPTOMATOLOGY. 

Take  a  case,  for  instance,  in  a  female  child  three  and  a 
half  years  of  age  I  saw  in  March,  1879.  The  child  had  for 
one  year  been  limping  a  little,  occasionally  complaining  of 
a  little  pain  at  the  knee,  and  crying  out  sometimes  during 
sleep.  The  mother  had  traced  out  a  fall  on  the  floor  which  oc- 
curred three  weeks  before  the  first  sign,  as  a  cause.  This 
first  sign  was  a  mere  awkwardness  in  gait,  the  right  limb 
being  favored.  A  few  days  later  there  was  ephemeral  pain. 
These  were  all  the  symptoms  noted,  and  they  would  become 
so  insignificant  that  advice  was  not  sought  until  the  date 
above  mentioned.  I  had  some  difficulty  myself  in  recogniz- 
ing the  limp,  could  not  discern  any  tenderness  in  or  about 
the  joint,  and  did  not  encounter  any  resistance  in  making 
passive  motion  except  in  flexion  beyond  ninety  degrees  and 
in  abduction.  There  was  no  pain,  and  yet  on  the  two  signs 
obtained,  and  the  history,  I  recorded  a  diagnosis  of  sus- 
pected bone-disease  in  the  neighborhood  of  the  hip.  A  few 
days  later  I  was  unable  to  arrive  at  anything  more  satisfac- 
tory, but  determined  to  keep  the  case  under  observation.  I 
did  not  have  an  opportunity  of  making  another  examina- 
tion until  the  beginning  of  October,  and  the  reason  the 
mother  gave  for  not  reporting  sooner  was  that  the  child 
got  "  perfectly  well  "very  soon  after  the  first  visit  in  March, 
and  continued  "well"  until  September,  when  she  began  to 
walk  lame  again  and  to  rest  poorly  at  night.  She  knew  no 
existing  cause  for  this  apparent  relapse.  I  found  exactly 
the  same  signs  I  found  in  March;  nothing  more.  Ten 
days  later  the  diagnosis  was  unquestionable. 

Now,  this  case  illustrates  the  slow  evolution  not  only  of 
the  pathological  process,  but  of  the  symptoms. 

Take  another.  A  girl,  eight  years  of  age,  whose  father  had 
died  of  rheumatisni,  and  mother  of  consumption,  came 
under  observation  in  May,  1880,  with  the  history  of  a  slight 
lameness  extending  over  a  period  of  two  months.  It  was 
reported  that  there  had  been  also  a  little  pain  about  hip 
and  knee.  She  cried  aloud,  too,  at  times,  during  sleep. 
The  limbs  were  parallel,  the  ilto-femoral  crease  was  short- 
ened, there  was  limited  rotation,  a  little  fulness  apparently 
about  the  trochanter,  and  she  walked  without  lameness. 
This  was  the  middle  of  the  month,  and  a  fortnight  later 
there  was  an  exacerbation,  marked  by  great  pain,  great 
tenderness,  inability  to  walk,  or  even  to  get  into  any  posi- 
tion at  all  comfortable.  This  subsided  under  rest  and 
anodynes,  and  by  midsummer  the  hip  and  limb  were  appa- 


230  DISEASES  OF  THE  HIP. 

rently  normal.  On  testing  the  functions,  however,  there 
was  found  moderate  yet  marked  resistance  in  all  directions, 
accompanied  by  pain,  and  one-inch  atrophy  of  the  thigh  by 
measurement.  The  atrophy  did  not  exist  in  May  prior  to 
the  exacerbation.  This  condition  of  apparent  restoration 
continued  until  the  latter  part  of  September,  when  she  was 
decidedly  lame,  and  complained  of  pain  on  the  inner  side  of 
the  knee.  The  day  before  she  was  trying  to  execute  a  fancy 
dance.  Rest  was  enjoined,  and  in  October,  one,  to  see  the 
girl  walk  and  dance,  would  never  suspect  the  slightest  im- 
pediment; yet,  on  critical  examination,  would  detect  the 
muscular  resistance  as  above  recorded.  Four  months  now 
elapsed  before  another  sign  developed,  and  this  was  a  cir- 
cumscribed fulness  below  the  trochanter,  attended  with  a 
little  pain.  The  query  as  to  abscess  was  noted  on  the 
records,  and  these  signs  continued  for  a  couple  of  months 
without  becoming  any  more  marked.  In  a  note  two  months 
later,  I  made  mention  of  the  insignificance  of  apparent  and 
the  significance  of  real  signs.  Quite  an  active  summer  was 
passed,  the  completeness  of  her  recovery  being  a  subject  of 
frequent  remark. 

The  family,  however,  noted  the  slight  lameness  after 
much  walking.  In  the  latter  part  of  August  I  found,  on  ex- 
amination, a  little  more  resistance  to  movement  than  I  had 
encountered  in  July.  The  atrophy  remained  as  before. 

From  this  time  to  August,  1882,  a  period  of  eleven 
months,  I  saw  her  frequently  and  could  not  get  any  joint 
tenderness,  or  anything  more  than  the  slight,  yet,  to  my 
mind,  important  signs  on  testing  the  joint  functions. 
There  was  no  exacerbation  whatever  during  this  period. 
The  lameness,  however,  had  become  gradually  more 
marked.  One  day  in  the  latter  half  qf  August  she  sud- 
denly became  very  lame,  and  complained  of  pain  in  the  hip 
and  at  the  knee,  all  without  known  provocation.  The 
symptoms  grew  gradually  worse,  and  within  a  week  the 
limb  had  assumed  the  characteristic  deformity  of  the  second 
stage.  The  most  violently  acute  pains  supervened,  the  ful- 
ness which  had  long  since  disappeared  reappeared  in  May, 
1883,  and  to-day  she  has  the  shortening,  the  deformity  and 
the  residual  abscess  of  the  third  stage.  Furthermore,  the 
abscess  has  opened,  hectic  has  appeared,  and  emaciation  is 
a  prominent  sign. 

The  number  of  cases  similar  to  this  is  not  small;  and 
there  occur  many  examples  of  dissatisfaction  on  the  part  of 


CHRONIC  ARTICULAR  OSTITIS  :   SYMPTOMATOLOGY.  231 

friends  with  any  kind  of  treatment.  Every  year  a  few  are 
brought  to  me  by  the  parents  recommended  frequently  by 
the  family  physician  for  diagnosis.  The  cases  are  already 
under  orthopedie  treatment;  but  because  of  the  slow  evolu- 
tion of  the  disease  and  the  remissions,  it  is  believed  that  the 
specialist  is  prompted  purely  by  mercenary  motives.  It  is 
very  seldom,  too,  that  on  examination  I  find  any  ground  for 
doubting  the  diagnosis  already  made,  and  for  questioning 
the  necessity  of  maintaining  the  same  careful  observation 
that  has  been  begun. 

In  my  search  last  winter  for  old  patients  that  had  ceased 
to  attend,  I  chanced  to  find  in  the  fourth  ward  of" the  city  a 
little  fellow  whose  history,  apart  from  the  amusement  it 
afforded,  was  very  instructive. 

The  case  was  in  a  boy  aged  four  years,  whom  I  saw  first 
in  the  latter  part  of  February,  1881.  The  office  record 
showed  that  we  had  found  him  limping,  favoring  the  left 
hip,  and  resisting  flexion  of  the  thigh  beyond  ninety 
degrees,  as  also  abduction  and  rotation,  while  the  adduc- 
tion stood  out  in  marked  reflex  contraction.  Extension 
was  perfect,  and  there  was  no  atrophy.  It  was  difficult  to 
learn  whether  he  had  any  pain  or  not.  He  had  been  lame 
for  one  week  only,  and  no  exciting  cause  for  this  lameness 
could  be  found.  The  diagnosis  of  articular  ostitis  at  the 
hip  was  recorded  without  even  the  mental  reservation  of  an 
interrogation  point,  and  by  way  of  treatment  rest  was  or- 
dered. When  he  returned  eight  days  later  for  observation 
it  was  learned  that  he  had  been  complaining  of  pain  about 
the  hip.  The  muscular  resistance  to  movements  was  still 
more  marked,  and  hyperextension  showed  a  beginning  re- 
sistance to  this  function.  There  was  also  an  appreciable  (?) 
amount  of  atrophy  of  the  thigh  and  calf.  The  diagnosis 
was  confirmed,  and  the  mother  so  informed.  This  was  the 
last  opportunity  I  had  for  examining  him  until  the  last  day 
of  February,  1883,  two  years  having  elapsed. 

On  entering  the  room,  the  mother  seemed  greatly  sur- 
prised, and  to  my  inquiries  concerning  her  boy,  replied: 
"Why,  he's  well  this  eighteen  months.  You'll  excuse  me, 
Doctor,  but  I'm  a  religious  woman,  and  when  you  gave  me 
so  unfavorable  opinion  about  the  little  fellow,  I  sought  the 
aid  of  the  parish  priest,  who  offered  six  or  eight  prayers 
over  him,  and  then  he  was  soon  well !" 

I  commended  her  for  her  faith,  and  asked  the  privilege 
of  examining  my  former  patient,  whom  I  saw  crouched  in 


232  DISEASES   OF  THE  HIP. 

a  corner  of  the  room.  She  consented  rather  grudgingly, 
and  on  getting  all  the  clothing  removed,  I  had  him  walk 
across  the  floor  while  Dr.  George  W.  Ryan  and  I  watched 
closely  for  any  defect  in  gait.  We  both  detected  a  slight 
degree  of  lameness,  or  rather  a  yielding  merely  to  that  side 
as  he  quickened  his  pace.  The  ilio-femoral  crease  was 
shorter  on  this  side  than  on  the  left,  and  in  the  groin  was  a 
little  fulness  not  marked,  yet  clearly  recognizable  on  com- 
parison. Flexion  was  not  as  complete  in  the  hip  formerly 
affected  as  in  the  other;  but  comparison  was  necessary  to 
elicit  any  resistance.  Abduction  could  be  made  to  the 
normal  extent  without  pain  or  resistance.  The  same  was 
true  of  inward  and  outward  rotation.  Abduction  was  not 
so  easily  executed  on  this  side  as  on  the  other.  There  was 
no  atrophy  in  any  part  of  the  limb  and  no  shortening.  The 
mother  averred  that  he  had  not  had  any  pain  since  the 
latter  part  of  the  spring  of  1881. 

Here,  now,  was  a  good  reason  for  maintaining  one  of  two 
propositions:  i.  That  there  had  been  an  error  in  diagnosis. 
2.  That  the  case  had  been  cured  by  miraculous  intervention. 
In  the  first  place,  I  am  quite  sure  that  the  case  is  not  an 
absolute  cure,  but  that  the  boy  is  enjoying  a  long  remission 
and  will  yet  come  to  the  exacerbation.  It  is  quite  rational, 
however,  to  suppose  that  the  disease  is  arrested  in  this  the 
first  stage,  and  that  the  signs,  as  at  present  existing,  are 
the  result  of  a  periarticular  lesion  of  an  obscure  nature, 
and  will  ultimately  disappear.  In  the  second  place,  I  do 
not  believe  that  any  power  superhuman  will  bring  about 
any  such  result  in  a  future  exacerbation.  It  will  be  observed 
that  the  atrophy  followed  in  the  case  just  preceding  this 
one  closely  on  the  second  exacerbation,  and  that  its  max- 
imum was  reached  within  a  short  time.  In  the  last  case 
cited  no  atrophy  has  taken  place. 

I  measured  a  six-year  old  boy  in  December,  1880,  in 
whose  case  there  were  signs  of  disease  at  the  hip,  the  signs 
admitting  of  no  doubt  whatever.  His  disease  began  rather 
acutely,  i.e.,  the  lameness  was  accompanied  from  the  begin- 
ning with  pain  and  the  ostitic  cry.  There  was  not  any 
atrophy.  I  measured  the  same  limb  one  year  later,  just 
after  a  second  exacerbation  (neither  of  which  was  very 
acute),  and  found  no  atrophy  whatever,  yet  he  had  favored 
the  limb  all  the  while,  and  it  seemed  a  little  longer,  but  in 
reality  was  not.  The  family  history  contained  a  specific 
taint. 


CHRONIC  ARTICULAR  OSTITIS :   SYMPTOMATOLOGY.  233 

It  would  seem  that  the  atrophy  was  in  direct  ratio  with 
the  acuteness  of  the  exacerbation,  and  depended  on  this 
element  in  the  disease.  Occasionally  one  meets  with  a  case, 
however,  that  would  seem  to  disprove  this  theory.  Take 
the  following,  in  a  girl  six  years  of  age,  who  was  admitted 
to  the  hospital  in  August,  1878,  with  a  history  of  symptoms 
dating  from  April,  1877.  It  was  stated  that  she  had  sharp 
pain  in  the  knee  during  the  first  few  weeks  after  the  inva- 
sion, and  then  this  subsiding  she  went  until  December,  only 
walking  a  little  lame,  when  a  severe  attack  of  pain  came  on, 
rendering  her  quite  helpless  for  several  months.  In  look- 
ing over  my  out-door  records,  I  found  the  same  patient 
entered  under  date  of  May  12,  1877,  there  being  at  that 
time  an  appreciable  degree  of  atrophy  and  a  history  of  one 
year's  lameness!  The  symptoms  had  been  very  insignific- 
ant; yet  this  atrophy  had  supervened.  To  estimate  the 
importance  of  atrophy  in  diagnosis  is  very  difficult.  That 
it  does  exist  clinically  all  admit.  Indeed,  it  is  one  of  the 
most  common,  if  not  the  most  common,  of  the  signs  in 
chronic  articular  ostitis.  Dr.  Shaffer  believes  that  the 
atrophied  muscles  exhibit  marked  diminution  in  farad ic 
contractility,  and  published  in  1877  a  paper  in  demon- 
stration of  this  position.  None,  I  believe,  deny  the  dimin- 
ished faradic  contractility  of  atrophied  muscles,  and  hence 
few  orthopedic  surgeons  have  availed  themselves  of  this 
faradic  test  in  arriving  at  a  diagnosis. 

Dr.  John  J.  Berry,  while  an  interne  of  the  Hospital  for 
the  Ruptured  and  Crippled,  analyzed  thirty  cases  of  artic- 
ular ostitis  of  the  knee,  and  many  more  with  other  affections 
of  the  knee  with  reference  to  this  very  point,  and  published 
his  conclusions  in  the  Medical  Record.  "The  result  of 
these  examinations  has  been  to  impair  our  confidence  as  to 
its  claims;  for  in  those  presenting  all  the  other  signs  of  os- 
titic  disease,  which  was  often  far  advanced,  the  contractility 
was  diminished  about  in  proportion  to  the  muscular 
atrophy,  the  responses  being  equally  good  in  those  cases 
presenting  the  same  condition  of  the  muscles  from  other 
causes."  This  so  well  expresses  my  own  impression  that  I 
have  given  the  extract  as  above. 

Now,  how  shall  we  explain  the  existence  of  the  atrophy  ? 
Sir  James  Paget,  in  his  "  Clinical  Lectures  and  Essays,"  calls 
it  reflex  atrophy;  and  according  to  this  author  it  is  "  due  to 
the  disturbance  of  some  nutritive  nerve-centre  irritated  by 
the  painful  state  of  the  sensitive  nerve-fibre."  I  agree  fully 


234  DISEASES  OF  THE  HIP. 

with  Dr.  Shaffer  in  regarding  the  "  state"  as  an  inflamed  one 
rather  than  a  painful  one. 

The  lameness  that  shows  itself  as  the  earliest  sign  is 
the  lameness  peculiar  to  bone  lesion.  One  soon  recog- 
nizes the  difference  between  this  and  the  lameness  of  a 
paralysis,  partial  or  complete.  There  is  something  about 
it  that  is  often  pathognomonic.  In  my  notes  I  have  come 
to  speak  of  it  as  the  "hip-limp."  Throughout  all  the 
stages  when  the  patient  does  walk  the  element  of  stiffness 
is  present.  True,  the  degree  varies.  At  first,  and  often 
for  a  long  time,  only  those  immediately  concerned  can  de- 
tect any  favoring  of  the  limb  at  all.  At  times  it  is  a  mere 
awkwardness;  the  child  does  not  raise  the  foot  so  high  as  the 
other  is  raised,  the  step  is  shorter,  and  all  the  time  the  little 
one  shows  a  degree  of  care  that  excites  in  the  parent  some 
apprehension.  Weeks  may  elapse,  and  sometimes  months, 
before  any  change  is  observed.  During  this  period  falls 
are  more  common,  and  after  one  of  these  accidents  a  well- 
marked  limp  is  developed.  Very  frequently,  in  seeking  the 
history  of  a  case,  have  I  found  this  peculiarity  of  gait  ante- 
dating the  fall,  to  which  the  disease  is  attributed,  and  often 
it  is  that  a  watchful  mother,  in  looking  back  over  the  case, 
volunteers  this  testimony.  Indeed,  with  the  pathology  of 
the  disease  in  mind,  one  can  readily  see  how  the  central 
ostitis,  while  limited  to  a  single  small  focus,  would  produce 
a  sign  so  apparently  insignificant.  Later,  the  gait  develops 
into  an  unmistakable  limp,  the  body,  as  the  step  is  taken, 
being  thrown  cautiously  to  the  side  on  which  the  disease 
exists.  There  is  not  that  confidence  in  the  limb  that  shows 
itself  in  the  other.  The  lameness,  too,  is  more  marked  after 
sleep.  The  muscles  seem  stiff,  and  after  a  little  while  this 
wears  off  in  a  measure.  Exceptionally,  it  is  more  exagger- 
ated toward  the  close  of  the  day,  if  the  child  have  been  at 
all  active.  From  the  inception,  then,  to  the  close,  it  may  be 
laid  down  as  a  constant  sign.  And  those  remarks  and 
statements  about  the  child  walking  "  perfectly  well,"  and 
entirely  free  from  lameness  are  to  be  taken  with  due  allow- 
ance for  the  inexactness  of  speech  and  the  natural  lack  of 
close  observation  in  the  laity.  Few  of  such  reports  will  bear 
the  test  of  rigid  cross-examination.  I  speak  now  advisedly, 
for  my  observation  on  this  point  has  been  very  close. 

Pain  of  a  reflex  nature  is  the  earliest  symptom,  and  this 
is  more  frequently  referred  to  the  knee.  The  richness  of 
the  nerve-supply  in  and  about  the  articular  structure  ren- 


CHRONIC  ARTICULAR  OSTITIS:   SYMPTOMATOLOGY.     235 

ders  the  parts  near  and  remote  peculiarly  susceptible  to 
pain.  The  grosser  lesions,  however,  do  not  cause  so  much 
pain  of  a  neuralgic  character  as  the  more  obscure  lesions. 
One  often  wonders  why  it  is  that  a  child  with  only  the  most 
obscure  signs  about  the  hip  has  so  much  pain,  and  vice 
versa. 

I  have  often  found  that  children  whose  parents  were  neu- 
rotic suffered  themselves  from  neuralgic  pains  on  apparently 
slight  provocation. 

Some  writers  on  this  subject  maintain  stoutly,  and  it 
seems  to  be  done  in  order  to  establish  a  theory  in  pathology, 
that  the  reflex  pains  in  the  knee-branches  of  the  obturator 
are  present  only  in  the  early  stage — the  stage,  according  to 
their  views,  of  synovitis.  If  there  is  one  symptom  more  than 
another  that  will  be  present  in  paroxysms  throughout  every 
stage  it  is  this  distressing  knee  pain.  Time  and  again  I  find 
it  here  in  the  hospital  wards  in  cases  far  advanced  in  the 
ulcerative  and  destructivevstages.  It  is  not  uncommon  to 
see  an  emaciated  boy,  wirh  the  hip  in  extreme  deformity 
and  the  thigh  covered  with  ulcers,  grasping  the  knee  with 
both  hands,  conscious  by  long  experience  that  pressure  will 
relieve  pain. 

The  obturator,  the  anterior  crural,  and  the  sciatic  are  often 
irritated,  and  give  the  symptoms  of  the  same  in  their  remote 
distribution.  Of  one  thing  I  am  convinced,  viz.,  the  unre- 
liability of  patients  in  their  statements  concerning  the 
dates  and  localities  of  pain.  In  the  last  case  to  which  I 
have  made  reference,  the  history  as  obtained  in  August, 
1878,  was  that  the  disease  first  made  itself  manifest  in  April, 
1877,  by  slight  pain  at  the  knee,  which  gradually  increased, 
etc.  Then  I  find  on  my  books,  under  May  12,  1877,  that 
she  had  been  walking  lame  for  a  year,  and  had  suffered 
occasionally  from  pain  in  the  knee  and  foot.  In  this  history, 
taken  so  shortly  after  April,  1877,  there  is  no  mention  made 
of  the  gradually  increasing  pain,  which  is  reported  a  year 
later  to  have  been  present  at  this  time.  The  only  sign  found, 
on  testing  the  movements  in  1877  was  a  little  resistance  to 
extreme  flexion.  My  attention  is  just  called,  too,  as  I  am 
writing  this,  to  some  inconsistencies  in  the  history  of  another 
case,  and  I  make  mention  of  them  as  illustrative  of  this  very 
point. 

On  our  Case  Books,  there  occurs,  under  date  of  May  *8, 
1870,  the  history  of  a  boy  eight  years  of  age.  It  is  stated, 
by  the  way,  that  there  is  no  scrofulous  taint  di^  io..erable. 


236  DISEASES  OP  THE  HIP. 

It  is  also  recorded  that  when  four  years  of  age  he  fell  from 
his  uncle's  arms  upon  the  ice,  and  that  his  "knee  was  im- 
paired;" that  the  knee  was  the  seat  of  pain  for  some  time; 
that  all  symptoms  then  subsided,  and  two  years  elapsed  be- 
fore another  exacerbation  appeared, 

In  another  history  of  the  case  as  published,  this  fall  on  the 
ice  occurred  when  he  was  eight  years  of  age — the  very  time 
when  he  entered  the  hospital  well  advanced  into  the  second 
stage.  This  fall,  too,  at  the  age  of  eight,  was  "  immediately 
followed  by  pain  about  the  hip."  On  the  25th  of  March, 
1883, 1  learned  the  following  facts  from  the  mother:  i,  That 
this  patient  died  about  two  years  ago;  cause  given,  con- 
sumption and  Bright's  disease;  2,  he  has  a  brother  with 
double  hip  disease,  now  in  the  Home  for  Incurables  on 
Randall's  Island;  3,  he  has  a  cousin  (whom  I  saw),  a 
daughter  of  the  mother's  sister,  hideously  deformed  from 
carious  disease  at  both  hip-joints;  4,  the  father  and  all  his 
family — mother,  brothers  and  sisters — died  consumptive  at 
comparatively  early  ages. 

It  may  be  safely  asserted  that  pain  is  present  in  every 
case,  especially  during  and  immediately  following  the  exa- 
cerbation. It  is  generally  regarded  as  a  clinical  fact,  how- 
ever, that,  exceptionally,  a  case  may  go  through  the  first 
stage,  and  even  the  second,  without  pain  at  hip,  knee  or 
ankle,  but  I  am  an  unbeliever.  I  do  believe  that  the  pain 
is  often  of  little  consequence  and  insufficient  to  excite  any 
apprehension.  Indeed,  I  have  seen  hips  with  cicatrices 
about  them  and  with  shortening  of  the  limb  wherein  the 
pain  and  inconvenience  have  been  so  slight  that  a  physician 
had  not  even  been  called. 

The  reflex  muscular  contractions  make  their  appearance 
very  early,  frequently  within  the  first  week,  and  continue 
with  remissions  through  all  the  stages.  It  requires  close 
examination  often  to  recognize  them,  and  a  comparative  test 
of  all  the  muscles  is  necessary.  The  same  cause  that  in- 
duces the  atrophy  and  the  pain  seems  to  operate  in  bring- 
ing about  the  muscular  spasm.  Resistance  is  offered  when 
flexion  is  made  beyond  eighty  degrees,  when  abduction  is 
attempted  and  when  external  rotation  is  carried  over  a 
small  arc.  This  is  early  shown  by  the  efforts  the  patient 
makes  to  get  the  shoe  and  stocking  on.  Indeed,  it  is  diffi- 
cult to  find  a  severer  test  to  a  hip  than  this  one  shoe-and- 
stocking  test. 

In  sor'*  instances  the  flexors  and  extensors  are  not  af- 


CHRONIC  ARTICULAR  OSTITIS :   SYMPTOMATOLOGY.     237 

fected.  A  boy  seven  years  of  age  was  admitted  to  the  hos- 
pital in  October,  1881,  with  a  history  of  the  ostitic  cry  and 
of  lameness  lasting  four  or  five  months.  There  was  noth- 
ing in  his  posture  to  excite  any  suspicion,  yet  the  natis  was 
broadened  a  little  and  the  crease  was  shortened.  Flexion 
was  made  to  the  full  normal  limit  without  the  slightest  re- 
sistance, and  both  extension  and  hyperextension  were  made 
with  equal  facility.  No  resistance  was  offered  when  ad- 
duction was  attempted,  but  when  abduction  was  made  to 
extreme  limits  a  perceptible  amount  of  resistance  was  rec- 
ognized, and  this  became  more  marked  when  rotation  was 
attempted. 

The  thigh  was  one  and  a  half  inches  smaller  than  its  fel- 
low, the  calf  a  half  inch,  and  yet  there  was  not  the  least 
tenderness  discoverable  at  the  joint  or  in  any  of  the  tissues 
thereabout.  It  was  difficult  to  account  for  so  much  atrophy 
and  so  little  muscular  resistance,  and  I  went  over  the  case 
again  with  much  care,  only  to  find  the  same  signs.  I  had 
no  hesitancy,  however,  in  making  a  diagnosis  of  articular 
ostitis,  and  I  kept  him  under  daily  observation  for  six 
months.  I  tested  the  hip  from  time  to  time,  and  the  free- 
dom of  flexion  and  of  extension  continued  intact.  The 
limb  gained  nearly  three  quarters  of  an  inch  in  girth,  and 
the  lameness  diminished  perceptibly.  While  I  did  not  con- 
sider the  disease  fully  arrested,  I  yielded  to  the  parents' 
request  for  his  discharge,  and  recorded  all  the  points  in  the 
examination  the  day  of  his  departure.  The  limbs  were 
parallel  and  he  walked  with  barely  a  trace  of  lameness. 
The  thigh  could  be  flexed  acutely  on  the  abdomen  without 
any  tilting  of  the  pelvis,  and  abduction  could  be  made  with- 
out any  resistance. 

To  hyperextension  and  to  outward  rotation  there  was 
slight  yet  unmistakable  resistance.  There  was  no  joint 
tenderness,  no  infiltration,  and  no  bony  enlargement.  "  In- 
deed, it  is  difficult  to  detect  any  bone  lesion,  yet  there  is 
strong  suspicion  that  he  has  it  and  that  this  may  some  day 
explode." 

The  mother  brought  him  to  me  one  month  from  the  date 
of  discharge  with  the  report  that  he  had  fallen  on  the  side- 
walk the  day  before,  straining  his  hip.  He  rested  poorly 
that  night.  I  found  considerable  joint  tenderness  but  no 
periarticular  infiltration.  A  counter-irritant  was  ordered 
and  directions  were  given  to  keep  the  boy  in  bed  for  a  few 
days.  He  was  better  in  a  week,  and  in  June  I  found  the 


238  DISEASES  OF  THE  HIP. 

movements  in  flexion  and  extension  unresisted.  Those  in 
abduction  and  rotation  were  resisted  more  than  at  date  of 
his  discharge.  Besides,  the  trochanter  major  was  enlarged 
and  reached  a  plane  farther  from  the  body  than  did  its 
fellow. 

The  same  signs  prevailed  in  July,  but  shortening  began 
then,  and  in  August  there  was  fully  a  half  inch  difference 
in  the  length  of  the  limbs.  The  same  freedom  of  extension 
and  flexion  was  found  in  October  after  an  examination, 
while  abduction  and  rotation  were  resisted  more  markedly 
than  before. 

In  some  cases  abduction  can  be  made  with  perfect  ease 
while  flexion  is  limited,  but  as  a  general  rule  all  the  arcs  of 
motion  are  limited,  and  it  is  very  often  the  case  that  the 
joint  movements  are  completely  locked  and  the  muscular 
spasm  can  be  easily  proven  by  an  anaesthetic.  Under  ether 
the  spasm  yields  and  no  resistance  is  encountered  since  ad- 
hesions within  or  immediately  surrounding  the  joint  have 
not  formed.  One  of  the  most  characteristic  signs  found  on 
grasping  a  thigh  in  a  case  of  bone  disease  at  the  hip,  is  the 
apparent  ankylosis  of  the  hip.  In  whatever  direction  the 
the  thigh  is  moved,  resistance  is  encountered  and  the  pelvis 
moves  with  the  limb.  This  is  often  the  deciding  point  in 
making  a  diagnosis. 

The  change  one  finds  in  the  contour  of  the  nates,  is 
a  flattening  not  due  entirely  to  muscular  atrophy.  The 
muscles  are  simply  in  a  state  of  rest,  the  weight  of  the 
body  is  thrown  on  the  other  limb,  and  this  limb  falls  na- 
turally at  rest.  This  is  one  of  the  oldest  signs,  and  is 
relied  on  with  much  faith  at  present  by  a  class  of  men  who 
deprecate  passive  movements,  holding,  as  they  do,  the 
theory  that  the  disease  begins  in  the  soft  structure  with- 
in the  joint.  With  the  pathological  views  I  hold,  however, 
I  have  come  to  place  very  little  reliance  in  the  gluteal  ap- 
pearances. These  muscles  do  not  participate  in  the  reflex 
contraction  so  peculiar  to  the  adductors  and  the  ilio-psoas. 
They  are  influenced  more  by  the  periarticular  infiltration 
and  by  the  position  of  the  trochanter.  At  a  later  period, 
broadening  takes  place  and  the  parts  have  such  an  appear- 
ance as  one  would  expect  to  find  when  the  acetabulum 
is  filled  by  a  foreign  substance  at  the  expense  of  the  head. 
In  the  early  stages,  too,  one  sometimes  finds  a  fullness  in  the 
gluteal  region,  imparted  to  it  either  by  the  extension  of  the 
inflammatory  lesion  to  the  bursa  in  the  vicinity,  or  by  the 


CHRONIC  ARTICULAR  OSTITIS :   SYMPTOMATOLOGY.     239 

appearance  of  an  abscess  springing  from  the  digital  fossa. 
This  sign  means,  of  course,  a  very  acute  exacerbation,  or  an 
acute  synovitis  going  on  to  suppuration.  The  latter,  how- 
ever, is  very  improbable. 

The  length,  shape,  and  position  of  the  ilio-femoral  crease 
depends  much  on  the  nature  of  the  disease.  Whether  it  be 
raised  or  shortened  or  lowered,  it  makes  little  difference  as 
a  clinical  sign.  In  the  first  few  weeks  of  a  chronic  ostitis, 
there  is  scarcely  any  change  ;  possibly  the  crease  will  be 
shortened. 

The  ostitic  cry  comes  a  little  later  than  the  lameness  or 
the  changes  in  the  nates.  It  is  usually  present  when  there 
is  pain  in  the  knee  by  day.  The  child  will  be  sleeping  very 
quietly  and  the  parents  will  be  startled  by  a  shriek  or  a  cry  ; 
go  to  the  crib  and  find  the  patient  still  asleep.  The  nerves 
are  irritated  by  the  inflammatory  process,  reflex,  contrac- 
tions of  the  muscles  take  place,  distorting  the  limb  and  per- 
haps crowding  together  parts  of  the  articular  surface  that 
are  hyperaemic,  the  cry  is  uttered  unconsciously  and  all  is 
quiet  again.  Where  the  limb  is  held  by  extension  appara- 
tus or  compressing  appliances,  so  that  the  muscular  con- 
traction cannot  take  place,  these  cries  are  not  made.  A 
frequent  repetition,  however,  of  these  nerve  irritations 
finally  awaken  the  child,  and  then  there  is  continuous  cry- 
ing. These  paroxysms  continue  generally  every  night  for 
a  week  or  two,  when  they  spontaneously  subside,  or,  rather 
they  continue  during  the  exacerbation.  Many  cases  I  have 
been  on  the  point  of  blistering  when  I  would  be  informed 
that  the  child  had  rested  well  during  the  past  night  or  two. 
Many  I  have  seen  yield  very  promply  to  a  fly-blister,  but, 
again,  it  is  my  observation  that  the  cries  do  not  cease  until 
two  or  three  nights  after  the  blister  has  been  applied.  They 
cease  very  promptly,  too,  on  the  application  of  extension. 
Indeed  it  is  one  of  the  most  common  observations  of  sur- 
geons to  find  a  child  sleeping  quietly  almost  immediately 
after  traction  on  the  limb  has  been  made  by  the  hand. 

One  of  the  strongest  arguments  for  traction  is  found  in 
this  very  relief  so  instantaneously  given.  All  men  bear  tes- 
timony to  it.  Traction  with  the  hand  necessarily  implies 
an  amount  of  fixation  so  that  the  good  result  may  come,  as 
Dr.  Judson  claims,  from  its  fixative  power. 

To  enumerate,  then,  the  symptoms  of  the  first  stage: 
Pain  on  rising  in  the  morning,  referred  generally  to  the 
knee,  but  often  to  other  points  in  the  distribution  of  the 


240  DISEASES  OF  THE  HIP. 

obturator,  the  anterior  crural  and  the  sciatic  nerves,  scream- 
ing during  sleep,  and  crying  aloud,  even  after  waking  out 
of  sleep.  There  is  also  associated  with  these  pains  a  hy- 
peraesthesia  of  other  nerves  in  the  neighborhood,  and  we 
have  a  tender  spine,  and  many  of  the  neuroses  belonging 
to  a  spinal  irritation,  or  a  genital  irritation. 

These  symptoms  are  of  an  irregularly  intermittent  charac- 
ter, coming  as  the  exacerbations  come,  and  going  as  they 
go.  This  is  the  rub;  but  the  ostitic  cries  may  be  present 
without  any  day  pain  or  any  apparent  tenderness. 

The  signs  are  in  the  order  of  their  appearance;  awkward- 
ness in  gait;  lameness  characterized  by  a  certain  degree  of 
stiffness  at  the  hip;  this  lameness  persisting,  differing,  how- 
ever at  times  in  degree;  loss  in  contour  of  nates;  reflex 
spasm  of  the  adductors  the  rotators  and  the  flexors  aggra- 
vated by  attempts  at  passive  motion,  and  atrophy  of  the 
thigh  muscles,  frequently  also  of  the  calf  group.  Such  are 
the  usual  and  most  common  signs  and  symptoms  in  the 
early  stage,  and  they  may  cover  a  space  of  time  varying 
between  one  month  and  three  or  four  years.  Be  it  remem- 
bered that  the  intervals  of  apparent  cure  or  arrest  of  the 
disease  are  longer  far  than  the  exacerbations,  and  that  the 
intervals  grow  less  frequent  and  shorter  in  proportion  to 
the  frequency  and  the  acuteness  of  the  exacerbations. 

There  are  irregular  types  presenting  from  time  to  time, 
and  they  seem  to  present  phases  not  found  in  the  regular 
types.  My  own  impression  is  that  the  early  stage  of  this 
affection,  given  a  correct  diagnosis,  presents  a  train  of 
symptoms  and  signs  that  are  pretty  uniform.  We  are 
often  intentionally  or  unintentionally  deceived  as  to  the 
symptoms,  by  the  parents  or  friends  bringing  the  patient, 
and  we  just  as  often  fail  to  elicit  all  the  signs  actually 
present  by  hasty  or  imperfect  examinations.  Symptoms 
may  differ  in  the  degree  of  severity,  and  signs  may  be 
more  or  less  marked — and  while,  for  instance,  it  may  be 
honestly  reported  that  a  child,  after  going  through  one  or 
two  unmistakable  exacerbations,  does  not  walk  the  least 
lame  for  many  months,  and  while  in  a  very  few  cases  this 
may  be  a  fact,  my  convictions  are  that  there  is  lameness 
all  the  while,  however  masked  it  may  be  by  the  fond 
wishes  of  a  parent  or  the  eagerness  on  the  part  of  the  med- 
ical attendant  to  record  the  fulfillment  of  a  prediction. 
Statistics  are  not  necessary  to  the  maintenance  of  the  prop- 
osition just  set  forth;  I  speak  after  having  made  statistics, 


CHRONIC  ARTICULAR  OSTITIS:   SYMPTOMATOLOGY.    241 

and  I  am  quite  sure  many  of  the  careful  observers  who 
practice  the  same  specialty  I  do  will  bear  me  out  with  their 
testimony. 

So  much  for  the  first  stage,  and  now  a  few  remarks  on 
the  second.  By  the  second  I  mean  the  stage  that  corres- 
ponds to  the  stage  of  pathological  perforation  either  into 
the  capsular  ligament  or  the  periarticular  structures.  It  is 
quite  true  that  often  in  an  acute  serous  synovitis  of  the  hip 
we  have  the  same  signs  that  accompany  a  purulent  syno- 
vitis. The  signs  of  an  acute  synovitis,  however,  soon  sub- 
side, and  if  bone  disease  be  the  cause  leaves  us  the  signs  of 
the  first,  or,  stage  of  ostitis.  The  most  natural  outlet  for  the 
pus  within  the  diaphysis  epiphysis  or  acetabulum,  is  into 
the  capsular  ligament;  and  the  specimens,  nearly  all,  show 
that  such  has  been  the  case.  Yet  there  are  instances  where  the 
pus  has  found  exit  without  the  capsule,  and  the  burrowing 
about  the  muscles  has  given  rise  to  deformity  such  as  we 
find  in  the  second  stage.  The  perforation,  too,  of  the  ace- 
tabulum may  take  place  where  the  greater  portion  of  the 
caseous  ostitis  is  concentrated,  and  the  outlet  for  matter 
here  is  either  into  the  obturator  muscle,  appearing  on  the 
nates  as  it  comes  through  the  small  sciatic  notch,  behind 
the  muscle,  the  pus  appearing  near  the  perineum  in  the  rec- 
tum or  in  the  vaginal  walls,  or  in  front  of  the  muscle,  the 
abscess  presenting  above  Poupart's  ligament.  (See  Fig.  6, 
page  45.)  The  symptoms  and  signs  under  the  above  circum- 
stance must  differ  according  to  the  groups  of  muscles  in- 
volved. The  suppurative  arthritis  that  most  commonly 
arises  in  the  progress  of  this  disease  has  certain  distinctive 
signs  at  its  inception  which  mark  the  beginning  of  the 
second  stage,  clinically  speaking. 

It  begins  in  an  exacerbation,  and  the  reflex  pains,  the  mus- 
cular spasm  and  the  atrophy  that  comes  on  at  this  juncture, 
differ,  as  above  mentioned,  very  little  from  the  synovitis  by 
contiguity.  The  persistence  of  the  signs,  however,  and  the 
appearance  of  new  signs  more  marked  render  the  clinical 
group  complete.  The  gradual  passage  from  the  first  into 
the  second  stage  may  be  illustrated  by  the  case  of  a  boy, 
aged  five  years,  whom  I  saw  in  May,  1872.  The  strumous 
diathesis  was  very  well  marked,  and  he  had  begun,  without 
any  known  cause,  to  complain  of  pain  in  the  hip  and  the 
knee,  having  walked  lame  a  few  days  before  the  beginning 
of  these  acute  symptoms.  This  pain  was  attended  with 
very  great  tenderness  in  and  about  the  hip,  an  increasing 


242  '    DISEASES  OF  THE  HIP. 

lameness,  the  ostitic  cry,  etc.  The  limbs  were  parallel  as 
he  stood,  and  at  this  date  the  limp  was  very  slight.  The 
natis  was  broadened  and  the  crease  lowered.  No  tender- 
ness on  concussion  or  percussion  could  be  elicited  at  the 
joint.  Muscular  resistance  was  offered  to  flexion  beyond 
eighty  degrees,  but  none  to  abduction  or  adduction  over  nor- 
mal arcs.  There  had  not  as  yet  been  any  atrophy.  In  accord- 
ance with  the  stereotyped  hospital  treatment  he  was  blistered 
and  poulticed,  and  being  anxious  myself  at  that  time  to  test 
the  efficacy  of  this  method,  in  a  case,  too,  of  so  recent  date, 
had  all  the  details  of  the  subsequent  poulticing  carried  out 
to  the  letter.  The  blister,  it  was  recorded,  fourteen  days 
after  its  application,  had  afforded  temporary  relief,  and  a 
second  was  applied. 

He  did  well,  i.e.,  had  no  acute  symptoms  until  the  first 
week  in  September,  when  tenderness  again  became  mani- 
fest, the  gait  was  more  awkward,  and  his  sleep  was  dis- 
turbed again.  The  second  exacerbation  was  approaching, 
and  being  fully  developed  by  the  i4th,  he  was  blistered  a 
third  time.  Within  ten  days  the  acute  symptoms  began  to 
subside,  and  by  November  he  was  in  a  comparatively  good 
condition.  In  January  he  was  still  going  around  quite 
actively  and  was  free  from  pain.  In  February  the  inguinal 
glands  were  observed  to  be  a  little  enlarged,  and  during 
the  first  two  weeks  of  the  month  he  grew  lamer,  the  glands 
increasing  in  size.  The  muscular  resistance  became  more 
marked,  deformity  now  began  to  show  itself,  and  this 
glandular  infiltration,  proved  to  be  only  a  part  of  a  more 
extensive  infliltration,  which  by  the  ist  April  had  devel- 
oped into  an  immense  abscess.  There  was  nothing  more 
than  the  deformity  to  mark  the  difference  between  the 
stages;  he  went  about  the  ward,  and  by  the  middle  of  May 
the  abscess  had  reached  huge  proportions,  hanging  be- 
tween the  thighs  like  a  large  scrotal  hernia.  It  opened 
spontaneously,  and  on  the  third  day  he  was  confined  to  bed 
with  hectic  fever.  Next  day,  however,  he  was  up,  and 
toward  the  last  of  June  it  was  recorded  that  not  an  un- 
toward symptom  had  occurred  since  that  one  day's  hectic. 
The  abscess  had  resulted  in  a  draining  sinus  and  the  de- 
formity had  become  less  marked.  In  July  it  was  apparent 
that  another  abscess  was  slowly  seeking  an  exit  on  the 
outer  aspect  of  the  thigh  in  its  upper  third.  It  increased 
to  a  great  size  without  special  inconvenience,  certainly  with- 
out constitutional  disturbance,  until  the  third  week  of  De- 


CHRONIC  ARTICULAR  OSTITIS :  SYMPTOMATOLOGY.    243 

cember,  when  it  opened.  This  was  not  followed  by  hectic, 
and  in  July,  1874,  another  abscess  opened,  apparently  spring- 
ing from  the  thyroid  foramen.  In  October  still  another, 
and  by  this  time  the  deformity  was  very  great.  The  posi- 
tion of  the  limb  was  that  of  sharp  flexion  and  rotation  out- 
ward. The  subsequent  history  is  not  pertinent  to  this 
chapter,  and  will  be  continued  in  another  for  the  final  re- 
sult. 

It  will  be  seen  that  this  case  began  with  an  exacerbation 
which  subsided  really  within  a  week,  for  when  the  boy  was 
admitted  he  had  no  symptoms,  only  a  few  signs  by  which  a 
diagnosis  could  be  made.  A  three  months  interval  followed, 
when  acute  symptoms  and  an  accentuation  of  the  signs 
marked  the  progress  of  the  case.  Within  a  fortnight  he 
was  better  again,  and  five  months  now  elapsed  before  the 
third  exacerbation  came  on.  This  was  less  acute,  indeed, 
than  the  other  two,  but  marked  the  close  of  the  first  stage, 
and  the  subsequent  history  of  the  case  demonstrated  quite 
clearly  that  this  had  been  the  beginning  of  the  second,  or, 
extra-osseous  abscess,  stage. 

The  case  of  a  boy  aged  six  years  who  entered  hospital 
September  2ist,  1878,  was  extremely  instructive  from  the 
interrupted  progress  to  the  second  stage.  Four  weeks  prior 
to  his  admission,  while  at  play  he  stepped  into  a  hole  in 
the  floor  and  is  thought  to  have  wrenched  the  hip,  but  he 
was  well  in  less  than  a  week.  A  week  subsequent  to  this 
apparent  recovery  he  was  quite  lame,  and  the  mother  de- 
tected a  difference  in  the  nates.  Symptoms  developed,  such 
as  pain,  restless  nights,  loss  of  appetite,  and  loss  of  flesh. 
When  I  examined  him,  the  right  limb  as  he  stood  was  ab- 
ducted a  little  and  advanced,  while  the  foot  was  inverted; 
lameness  was  very  marked.  The  thigh  was  flexed  at  an 
angle  of  150°,  and  -extension  beyond  this  angle,  as  well  as 
abduction, were  much  resisted.  Flexion  was  resisted  beyond 
ninety  degrees.  Indeed,  all  the  signs  went  to  show  that 
this  was  a  case  in  an  acute  exacerbation.  A  liniment  and 
a  roller  were  applied,  and  by  the  2d  of  October  the  re- 
lief was  so  great  that  serious  doubts  were  recorded  as  to  its 
being  a  case  of  articular  ostitis.  Improvement  was  unin- 
terrupted, and  on  November  gih  he  was  removed.  It  re- 
quired a  very  thorough  examination  then  to  convince  me 
that  there  was  a  chronic  ostitis  still  present. 

He  returned  in  the  following  March,  and  while  the  limp 
and  the  other  signs  pointed  unmistakably  to  the  disease 


244  'DISEASES  OF  THE  HIP. 

originally  diagnosticated,  there  were  no  symptoms.  The 
little  fellow  had  just  passed  through  an  exacerbation  at 
home.  During  the  first  week  of  April  he  began  to  complain 
of  pain,  to  walk  lamer,  and  to  rest  poorly  at  night.  A  blister 
was  applied  the  evening  of  the  7th,  and  on  the  icth  it  is  re- 
corded that  he  had  derived  no  benefit  therefrom.  This,  in 
fact,  was  the  beginning  of  the  second  stage,  and  instead  of 
gaining,  as  he  had  done  on  former  occasions,  he  grew  rapidly 
worse.  A  day  or  two  later  it  was  observed  that  he  lay  abed 
on  the  left  side  with  the  right  thigh  flexed  and  at  an  angle 
of  ninety  degrees,  and  he  cried  aloud  if  the  least  move- 
ment was  attempted.  In  a  few  days  he  was  induced  to  oc- 
cupy a  rolling  chair,  and  it  was  noted,  near  the  close  of 
September,  as  he  stood  by  a  chair,  that  the  limb  was  everted 
rotated  outward,  and  flexed  at  an  angle  of  about  ninety 
degrees.  The  superficial  and  deep  inguinal  glands  were 
infiltrated,  and  for  the  first  time  now  could  any  atrophy  of 
the  thigh  be  detected. 

It  not  infrequently  happens  that  a  case  is  doing  remarkably 
well  and  indications  seem  to  point  strongly  to  an  arrest 
of  the  disease  in  the  first  stage  when  a  fall  or  injury  will  be 
speedily  followed  by  the  most  acute  symptoms  ushering 
in  the  second  stage.  I  well  remember  the  congratulations 
with  which  I  was  indulging  myself  on  the  rapid  strides 
toward  recovery  of  a  boy  who  was  in  the  hospital 
in  1873.  He  was  only  six  years  of  age,  and  had  been  ad- 
mitted in  the  beginning  of  the  year  with  pretty  well  marked 
signs  and  a  few  subacute  symptoms  of  disease  at  the  hip. 
A  few  reflex  symptoms  not  in  the  nature  of  an  exacerbation 
were  present  at  odd  intervals  during  the  first  six  months  of 
his  stay,  and  in  June  he  was  the  most  active  boy  on  the 
ward.  On  superficial  observation  no  disease  could  be  rec- 
cognized.  In  the  early  part  of  July  some  carpenters  were 
at  work  and  this  boy  climbed  the  scaffolding  one  day  and 
fell  a  distance  of  six  or  eight  feet,  his  hip  coming  in  con- 
tact with  the  hard  floor.  On  getting  up  he  could  scarcely 
walk  and  there  was  much  extra  heat  in  the  soft  parts.  He 
was  kept  in  bed  with  cold-water  dressings,  but  at  the  end 
of  a  week  the  symptoms  were  more  acute,  deformity  had 
followed  quite  rapidly,  and  despite  repeated  blisterings  the 
case  went  on  to  abscess.  The  final  result,  with  sketch  of 
patient,  can  be  seen  on  page  335  I  had  under  observa- 
tion in  1877  a  case  with  many  obscure  neuroses  in  a  boy 
ten  years  of  age.  He  had  been  complaining  of  pains  in 


CHRONIC  ARTICULAR  OSTITIS  :   SYMPTOMATOLOGY.   245 

his  right  thigh  for  a  year  when  I  first  saw  him  in  June, 
1877,  and  had  been  limping  for  six  months.  I  could  get 
only  spinal  symptoms,  and  directed  my  treatment  to  that 
region,  thinking  it  might  be  a  neurosis  of  the  hip.  It  was 
fully  two  months  before  I  could  get  any  signs,  save  the 
lameness,  of  disease  at  the  hip.  He  continued  under  treat- 
ment in  the  out-door  department  until  April,  1878,  attend- 
ing very  regularly  and  exciting  a  vast  amount  of  interest 
by  reason  of  the  shifting  of  the  symptoms  from  spine  to 
hip,  and  vice  versa.  My  notes  show  a  pretty  clear  history, 
though,  of  progressive  chronic  ostitis  confined  more  exclu- 
sively to  the  diaphysis. 

He  came  into  the  hospital  the  middle  of  April,  and  the  case 
was  still  very  obscure.  I  had  from  the  beginning  placed  my- 
self on  record  as  diagnosticating  bone  disease,  and  although 
the  signs  were  few  they  were  sufficiently  well  marked  to  be 
diagnostic.  A  month  subsequently  it  is  recorded  that  three 
or  four  days  ago  he  received  a  kick  from  a  playfellow  just 
below  the  knee  while  sitting  in  a  chair,  and  since  that  acci- 
dent he  has  been  crying  out  during  sleep,  and  even  awaking 
out  of  sleep,  crying  out  with  pain  in  hip  and  knee.  At  this 
time  he  was  scarcely  able  to  walk  and  he  moved  about  in  a 
rolling  chair.  No  contusion  can  be  found  superficially,  and 
the  hip  joint  must  have  suffered  a  concussion  resulting  in 
rupture  of  the  cartilage  of  incrustation  at  some  point  per- 
mitting escape  of  pus  into  the  articular  cavity.  Possibly 
this,  and  possibly  only  a  serous  synovitis  by  contiguity.  At 
all  events,  acute  symptoms  remitted  in  a  few  days  only  to 
appear  again  shortly  afterwards,  and  his  limb  from  this 
time  forward  gradually  assumed  the  flexed  position,  while 
the  pelvis  assumed  a  higher  plane.  The  trochanter  became 
more  prominent  and  the  joint  movements  were  to  all  in- 
tents locked. 

I  could  not  help  but  regard  this  as  a  rather  extraordinary 
case  in  the  lateness  of  the  development  of  the  bone  disease 
and  in  its  exceedingly  slow  evolution  ;  for  it  will  be  remem- 
bered that  the  boy  was  fully  eight  years  of  age  when  the  first 
symptoms,  such  as  pain  and  hyperaesthesia,  appeared.  Then 
a  period  of  six  months  elapsed  before  the  mother  recognized 
any  lameness.  Still  more  curiously,  for  two  or  three  months 
k  after  coming  under  my  own  observation,  no  resistance  to 
movements  in  any  direction  or  to  any  normal  extent  could  be 
detected.  Yet  he  had  the  undoubted  hip-limp,  and  on  this 
I  based  my  diagnosis.  The  mode  of  passing  into,  the  second 


246  DISEASES  OF  THE  HIP. 

stage  was  very  nearly  according  to  rule.  It  is  seldom  that  a 
genuine  central  ostitis,  unless  acute  in  character,  goes  rapid- 
ly into  the  second  stage.  I  have  searched  my  notes  rather 
diligently  and  I  am  able  to  find  only  a  few.  Be  it  under- 
stood, however,  that  I  am  not  referring  to  cases  occurring  in 
children  beyond  the  tenth  year,  when  the  probabilities  are 
that  the  disease  began  either  as  a  synovitis  or  as  a  periostitis. 

Most  cases  pass  almost  insidiously  from  the  first  into  the 
second  stage,  and  the  line  cannot  be  drawn.  In  out-patients 
one  can  very  often  see  them  at  one  date  presenting  the 
signs  peculiar  to  the  first  stage,  and  at  the  next  visit  signs 
of  the  second  stage  will  be  present.  In  hospital,  however, 
where  you  see  cases  day  after  day,  you  can  only  record  in 
the  vast  majority  "gradually  passing  into  the  second  stage." 

A  little  girl  five  years  of  age  was  admitted  to  the  hospital 
in  the  early  part  of  1873,  and  the  family  history  was  de- 
cidedly strumous.  The  child,  two  years  prior  to  date  of 
admission,  had  begun  to  walk  lame  and  to  complain  of  pain 
in  the  knee,  then  in  the  hip.  Although  she  had  passed 
through  at  least  two  exacerbations,  one  of  which  was  un- 
usually acute,  she  still  presented  the  signs  of  the  first  stage, 
without  any  atrophy  even.  The  lameness  and  the  reflex 
spasm,  on  movement,  were  very  characteristic.  During  the 
months  of  March,  May  and  June  I  had  nothing  to  record 
in  the  way  of  change  except  an  occasional  sign  of  pain,  which 
would  pass  away  as  it  came.  The  deformity  imperceptibly 
increased  all  the  while,  and  the  spasm  grew  more  marked. 
By  November  the  second  stage  signs  were  well  established, 
and  these  continued  with  progressive  steps  until  an  attack 
of  pertussis,  six  months  later,  reduced  her  to  such  a  degree 
that  the  displacements  of  the  third  stage  began  to  make 
their  appearance. 

The  progress  in  another  girl,  a  year  or  two  older,  who 
was  in  the  hospital  from  April  to  the  following  September, 
was  very  similar  to  that  in  the  one  just  narrated.  She  had 
a  slight  exacerbation  very  soon  after  her  first  signs,  six 
months  before  her  admission,  and  was  fairly  established  in 
a  second  exacerbation  at  the  time  she  came  into  the  hos- 
pital. She  seemed  to  rally  from  this  with  very  little  diffi- 
culty, but  it  was  only  a  faint  remission.  The  symptoms  re- 
sumed their  severity,  and  in  June  a  fulness  appeared — the 
first  sign  of  abscess — and  the  deformity  slowly  increased, 
so  that  in  August  the  case  was  well  advanced  into  the 
second  stage. 


CHRONIC  ARTICULAR  OSTITIS  :   SYMPTOMATOLOGY.  247 

The  duration  of  this  stage  is  variable,  yet,  as  a  rule,  not 
so  long  as  the  first.  The  disease  may  be  arrested  before 
the  third  is  reached,  but  this  is  not,  as  some  would  imagine, 
a  termination.  Treatment  may  and  often  does  render  such 
protection  to  the  joint  that  the  processes  of  repair  begin 
before  any  bony  displacements  take  place.  It  is  very  safe, 
however,  to  predict  that  a  limb  will  shorten  from  bony 
changes  at  the  upper  end,  in  a  case  where  the  weight  of  the 
body  is  constantly  brought  to  bear  upon  the  repairing  pro- 
cess at  so  great  a  disadvantage  as  takes  place  in  a  limping 
patient.  The  angle  at  which  the  neck  meets  the  shaft  will 
most  assuredly  change,  and  the  trochanter  will  rise  above 
Nelaton's  line,  even  though  the  articular  extremity  remains 
undestroyed. 

It  is  my  custom  to  designate  that  as  the  second  stage 
when  the  limb  presents  a  well-marked  though  not  exagger- 
ated deformity,  with  either  apparent  lengthening  or  appar- 
ent shortening  of  the  limb.  The  patient  usually  bears  the 
entire  weight  on  the  sound  limb  standing,  while  the  limb 
of  the  diseased  side  hangs  in  flexion  and  outward  rotation. 
Some  authors  regard  this  position  of  the  limb  as  caused  by 
distention  of  the  capsular  ligament.  So  far  as  my  own  ob- 
servations go,  and  so  far  as  my  study  of  the  arguments  pro 
and  con  go,  I  must  dissent  from  this  as  the  cause.  In  many 
cases  where  one  can  detect  by  palpation  the  abscess  as  it 
springs  from  the  digital  fossa,  the  limb  is  not  in  this  posi- 
tion. The  amount  of  rotation  varies,  and  the  amount  of 
flexion  varies.  Often  the  limb  is  not  rotated  either  way, 
but  is  held  rigidly  in  flexion.  The  nerve-supply  to  the  joint 
is  in  intimate  connection  with  all  the  periarticular  muscles, 
and  especially  those  concerned  in  adduction  and  flexion. 
The  ilio-psoas  is  an  outward  rotator,  as  well  as  a  flexor,  and 
it  is  an  anatomical  fact  that  the  muscles  concerned  in  the 
different  angular  movements  act  as  outward  rotators.  Thus 
we  have  the  chief  flexors — the  ilio-psoas,  all  the  adductors, 
the  two  chief  adductors,  and  the  great  extensor  [Morris]. 
It  is  not  rational  to  suppose  that  the  whole  cavity  is  filled 
with  pus  as  soon  as  the  perforation  takes  place  into  the  joint, 
either  through  the  cartilage  of  the  head  or  the  cartilage  of 
the  acetabulum.  Even  if  it  did,  the  muscles  would  not 
yield  so  promptly  to  the  efforts  of  the  limb  to  assume  the 
position  it  would  naturally  assume  when  divested  of  these 
surrounding  structures.  By  the  time,  too,  that  this  stage 
in  the  pathological  process  is  reached  inflammatory  pro- 


248  DISEASES  OF  THE  HIP. 

cesses  have  extended  to  the  intra-  and  extra-articular  tis- 
sues, thus  limiting  the  movements  as  well  by  inflammatory 
neoplasia  as  by  additional  irritation  of  nerve-filaments 
traversing  these  products. 

To  be  more  explicit,  then.  The  clinical  second  stage  of  a 
chronic  articular  ostitis  of  the  hip  begins  with  the  establish- 
ment of  permanent  deformity,  due  to  muscular  contraction, 
and  ends  with  the  establishment  of  the  deformity  dependent 
upon  bony  changes  and  displacements.  There  is  no  short- 
ening in  this  stage,  although  it  may  be  apparent;  there  is 
no  lengthening,  although  this  is  called  the  stage  of  elonga- 
tion. Not  that  any  orthopedists  or  any  general  surgeons 
really  believe  that  there  is  any  elongation;  but  theories  have 
declared  such  to  be  the  case,  and  for  this  reason  the  name 
is  sometimes  retained.  The  tilting  of  the  pelvis,  and  not 
the  capsular  distension,  is  now  generally  recognized  as 
the  cause  of  the  apparent  lengthening.  The  tilting  upward 
of  the  affected  side  of  the  pelvis  not  infrequently  occurs,  and 
then  we  have  apparent  shortening,  although  the  capsular 
ligament  may  be  fully  as  much  distended. 

The  escape  of  the  pus  into  the  periarticular  structures 
occurs  first  during  the  second  stage,  and  the  suppurative 
process  becomes  fully  established;  so  that  one  naturally  be- 
gins to  look  for  abscess,  and  if  the  symptoms  are  unusually 
acute  and  unusually  persistent,  the  anxiety  is  all  the  greater. 
I  would  not  for  an  instant  be  understood  as  saying  that  the 
approach  of  abscess  is  always  accompanied  by  acute  or  es- 
pecially painful  symptoms.  Far  from  it;  for  these  pus  sacs 
present,  very  often  without  any  premonitory  symptoms,  if 
we  can  rely  on  histories;  but  I  am  prepared  to  state  from 
my  daily  hospital  experience  that  there  are  premonitory 
symptoms  in  nearly  every  case.  I  think  if  I  were  to  search 
my  records  closely  I  should  be  at  a  loss  to  find  a  single 
case  in  which  the  abscess  was  not  preceded  by  several 
weeks,  it  may  be,  by  certain  vague  pains  about  knee  or 
hip  called  neuralgia,  a  certain  amount  of  restlessness  at 
night,  attributed  to  indigestion  or  constipation. 

I  have  in  mind  now  the  case  of  a  little  girl  who  came  un- 
der observation  in  July,  1878.  She  was  at  that  time  four 
years  of  age,  and  the  initial  lameness  began  nearly  a  year 
previously  in  the  wake  of  an  intermittent  fever.  The  second 
stage  was  ushered  in  by  a  very  severe  exacerbation  a  few 
months  before  admission.  She  entered,  therefore,  with 
deformity,  and  the  angle  at  which  the  limb  was  held  was 


CHRONIC  ARTICULAR  OSTITIS  :  SYMPTOMATOLOGY.  249 

120°.  There  was  no  shortening,  but  three-quarters  of  an 
inch  atrophy  of  thigh.  This  child  had  also  what  is  quite 
common  in  this  stage,  as  well  as  in  the  third,  viz.,  a  com- 
pensating lordosis  in  the  lumbar  region. 

On  admission,  she  was  in  the  midst  of  an  exacerbation  of 
a  mild  type,  and  counter- irritation  was  followed  by  relief. 
Nothing  further  occurred  worthy  of  any  note  until  the 
latter  part  of  March,  1879,  when  she  had  a  recurrence  of 
some  malarial  symptoms,  which  continued  with  remissions 
for  a  couple  of  months.  No  other  note  occurs  again  until 
August,  1880,  when  it  was  simply  recorded  that  the  de- 
formity without  any  pains  or  other  symptoms  had  reached 
ninety  degrees.  Her  case  was  considered  a  cure  in  the 
second  stage,  and  it  was  thought  also  that  it  furnished  a 
fine  example  of  a  caries  sicca.  Circumstances  were  such 
that  she  remained  in  the  hospital,  and  she  has  been  as 
closely  observed  as  if  she  were  a  patient.  Her  gait  has 
been  remarkably  good,  and  even  graceful  withal. 

One  day  in  April  of  the  present  year  the  nurse  called  my 
attention  to  a  soft  tumor  at  the  junction  of  the  upper  with 
the  middle  thirds  of  the  thigh,  outer  aspect.  I  said,  here  is 
a  case  in  which  the  abscess  appeared  without  premonition  of 
any  kind.  I  remembered,  however,  that  she  had  been  com- 
plaining during  the  past  winter  at  odd  intervals,  and  on 
reverting  to  my  notes  found  that  in  March,  1882,  she  had  an 
exacerbation  lasting  a  few  days  and  subsiding  spontane- 
ously. Similar  attacks  occurred  in  October  and  November, 
and  she  was  blistered  once  or  twice. 

The  locality  of  abscess  is  most  frequently  under  the  ten- 
sor vaginae  femoris,  or  in  this  immediate  neighborhood. 
Another  favorite  site  is  on  the  outer  side  of  the  thigh  near 
the  junction  of  the  upper  with  the  middle  thirds,  and  from 
this,  as  a  starting-point,  the  pus  dissects  up  the  fascia,  and 
we  find  not  infrequently  an  abscess  extending  from  tro- 
chanter  to  condyle. 

It  must  not  be  forgotten  that  this  stage,  like  the  first,  is 
marked  by  exacerbations.  At  times  when  acute  symptoms 
prevail  the  deformity  may  be  very  great,  and  the  reflex  con- 
tractions may  arrest  any  movement,  however  slight.  A 
little  later,  in  the  intervals,  one  may  find  smooth  motion 
over  an  arc  of  seventy  or  eighty  degrees. 

The  changes  in  the  nates  are  even  more  exaggerated  than 
in  the  first  stage.  We  find  a  very  broad  natis,  and  if  ab- 
scess underlies,  the  contour  differs  still  more  markedly 


250       .  DISEASES  OF  THE  HIP. 

from  the  normal.  The  spine  begins  to  adapt  itself  to  the 
joint  deformity,  and  the  lumbar  region  presents  an  antero- 
lateral  curve,  the  convexity  forward  and  to  the  side  oppo- 
site the  bone  diseased.  This  is  purely  compensatory,  and 
changes  as  the  angle  of  flexion  at  the  hip  changes.  (See 
Figs.  25,  26  and  27.)  By  suspending  the  patient  or  by 
having  him  sit  upon  a  level  surface  the  curve  will  disap- 
pear. So  likewise  this  can  be  accomplished  by  lying  on  the 
back  with  the  limb  held  in  its  abnormal  position. 

The  third  stage  presents  clinical  signs  in  accordance  with 
the  bone  changes.  The  steps  from  the  second  to  the  third 
are  sometimes  as  gradual  as  those  from  the  first  to  the 
second;  sometimes  they  are  very  abrupt.  This  stage  may 
be  defined  in  clinical  terms  as  the  stage  wherein  real  short- 
ening of  the  limb  makes  its  appearance — pathological 
shortening — and  wherein  the  deformity  is  dependent  mainly 
on  the  bone  changes,  the  limb  assuming  positions  conso- 
nant with  the  portions  of  head,  neck  or  acetabulum 
destroyed. 

For  instance,  if  the  upper  rim  of  the  acetabulum  is  ca- 
rious, and  hence  insubstantial  as  a  border  against  which  the 
head  rests,  the  limb  would  naturally  be  adducted  and  ro- 
tated either  inwards  or  outwards.  Inwards,  if  the  anterior 
part  of  the  head  had  broken  down  first;  outwards,  if  the 
posterior  portion  had  been  the  first  to  give  way.  There  are 
cases  where  the  limbs  preserve  their  parallelism,  and  the 
deformity  is  most  marked  in  the  gluteal  region  when  the 
projecting  trochanter  gives  the  appearance  of  a  dorsal  dislo- 
cation. When  the  lower  portion  of  the  acetabulum  has 
been  the  seat  of  disease,  and  the  limb  during  the  second 
stage  has  been  in  flexion  and  outward  rotation,  fusion  is  apt 
to  take  place  between  the  necrotic  head  and  the  carious 
acetabulum.  Then  the  deformity  differs  very  little  from 
that  of  the  second  stage.  The  most  common  position  for 
the  limb  to  assume,  however,  in  this  stage  is  flexion,  ro- 
tation inwards  and  adduction.  In  this  position  most  of  the 
limbs  can  be  found,  and  in  this  position  most  of  the  limbs- 
are  left  after  expectant  treatment. 

We  have  now  in  hospital  a  boy  who  was  admitted  early 
in  1881.  He  was  then  seven  years  of  age  and  had  begun  to 
favor  the  limb  in  walking  three  weeks  before  his  admission. 
He  did  not  complain  of  any  pain,  and  his  lameness  was  the 
only  evidence  that  there  was  any  tenderness  about  the 
joint.  In  fact,  I  saw  him  when  he  had  been  limping  only  a 


CHRONIC  ARTICULAR  OSTITIS  !   SYMPTOMATOLOGY.  2$  I 

week,  and  could  not  elicit  any  tenderness  by  a  pretty  careful 
examination.     The  maternal  history  was  tuberculous. 

On  the  day  of  his  admission  I  found  it  quite  easy  to  flex 
the  left  thigh — the  one  he  favored — to  an  acute  angle.  By 
comparison  the  angle  was  equal  with  that  on  right  side; 
but  when  the  extreme  limit  was  reached  the  boy  winced.  I 
could  extend  the  thigh  to  the  normal  degree  without  any 
tenderness.  Abduction  was  very  nearly  perfect  and  quite 
painless,  adduction  perfect,  though  causing  a  little  pain. 
Rotation  inward  and  outward  was  not  only  resisted  a  trifle, 
but  caused  pain.  He  referred  what  pain  he  had  experienced 
to  the  trochanter  and  to  the  front  of  the  right  knee.  There 
was  a  little  change  in  the  contour  of  the  natis,  and  the  ilio- 
femoral  crease  was  a  shade  shorter  than  that  of  the  opposite 
side.  Atrophy,  shortening,  and  tenderness  at  the  articular 
surfaces  had  not  yet  presented.  The  treatment  employed 
was  purely  expectant,  in  accordance  with  the  hospital  rules; 
and  while  his  lameness  progressively  advanced,  there  was 
no  symptom  until  the  beginning  of  February,  when  the 
parts  about  the  hip  seemed  unusually  tender  and  were  sub- 
jected to  the  usual  local  treatment,  during  which  he  was  not 
allowed  to  walk  about  the  ward.  This  exacerbation  ran  its 
course  in  a  week,  and  he  then  moved  around  very  easily  until 
the  third  week  in  April,  when  he  had  pain,  and  was  able  no 
longer  to  walk.  Furthermore,  he  cried  out  during  sleep, 
notwithstanding  the  details  of  treatment  had  been  fully 
carried  out,  and  by  the  last  of  the  month  his  symptoms  and 
signs  were  those  of  the  second  stage. 

About  the  middle  of  May  the  inguinal  glands  were  infiltra- 
ted and  the  gluteal  region  presented,  on  palpation,  a  similar 
condition.  He  became  anaemic,  and  one  month  later  I  dis- 
covered a  small  fluctuating  tumor  on  the  anterior  and  outer 
aspect  of  the  thigh  lying  beneath  the  tensor  vaginae  femoris. 
Within  ten  days  this  tumor  had  become  quite  distinct  to  the 
eye,  and  above  the  trochanter  springing  apparently  from  the 
digital  fossa  another  tumor  was  recognized,  cystic  in  nature. 
At  this  time  he  was  not  suffering  to  any  great  extent  from 
pain,  but  was  comparatively  comfortable.  From  this  date  to 
the  beginning  of  July,  1882,  the  case  progressed  slowly  with- 
out notable  changes.  The  gluteal  tumor  had  by  this  time 
become  a  large,  fluctuating  mass  without  acute  symptoms. 
The  deformity  of  the  thigh  was  in  flexion  at  about  135°,  and 
rotation  outward  over  a  small  arc.  Late  in  September  this 
abscess  opened  spontaneously,  and  in  ten  days  he  was  suf- 


DISEASES  OF  THE  HIP. 

fering  from  hectic,  was  losing  ground,  and  he  had  a  laryn- 
geal  cough.  These  symptoms  did  not  continue  long,  and 
the  next  note  I  have,  records  extensive  ulceration  of  the 
skin  around  the  opening.  This  was  in  January  of  the 
present  year.  In  February  another  abscess  appeared  on 
the  inner  side  of  the  thigh  near  the  perineum,  and  in  a  few 
weeks  this  opened,  the  skin  sloughing.  During  this  period 
he  rested  well  nights  and  was  comparatively  free  from  pain. 
The  rotation  outward  became  less  marked,  and  by  the  first 
of  June  there  was  a  slight  amount  of  inward  rotation. 
About  this  time  he  began  to  suffer  from  great  pain  about 
the  knee,  and  it  yielded  very  imperfectly  to  anodynes.  At 
present  his  gluteal  region  presents  one  boggy  mass  of  inflam- 
matory products,  and  the  thigh  is  pretty  well  covered  with 
ulcers  and  necrotic  bits  of  integument.  He  is  thin  even 
to  emaciation,  yet  goes  about  on  crutches  with  more  ease 
than  one  would  imagine.  The  hip  is  practically  locked 
against  any  movement,  and  his  shortening  is  about  an  inch 
and  a  half. 

This  history  I  have  narrated  without  abridgment.  It 
records  a  bad  case  and  gives  the  steps  from  the  first  to 
the  second  stage,  and  then  from  the  second  to  the  third. 
I  have  not  had  occasion  to  suspect  any  amyloid  changes  as 
yet.  I  should  not  give  vent  to  any  words  of  surprise  did 
these  changes  manifest  themselves  before  the  close  of  the 
present  year.  The  family  history  predisposes  to  this  com- 
plication, and  yet  I  have  the  records  of  many  who  have 
passed  through  just  such  stages,  and  have  suppurated  as 
freely,  emerging  from  it  all  with  bony  ankylosis,  and  with 
useful  limbs.  We  have  at  present  in  the  female  wards  a 
child  now  ten  years  of  age,  the  skin  and  soft  parts  over 
whose  hip  and  thigh  present  one  net  work  of  cicatricial 
tissue,  whose  angle  of  deformity  is  135°  and  whose  shorten- 
ing is  two  inches.  She  has  a  very  useful  limb  and  yet  her 
face  indicates  the  highest  type  of  the  strumous  diathesis. 

It  is  difficult  to  find  patients,  especially  in  the  early  years 
of  life,  wherein  such  extensive  ulceration  occurs.  In  those 
cases  where  the  bone  lesion  seems  to  start  from  the  peri- 
phery, the  passage  from  the  second  to  the  third  stage  is  more 
acute — the  abscesses  when  they  do  present  are  more  numer- 
ous and  the  sloughing  is  more  extensive.  A  good  many 
run  a  course  like  that  in  a  hearty-looking  girl  aged  seven 
years,  who  came  into  the  hospital  early  in  the  autumn  of 
1880.  The  family  had  observed  her  limping  about  six 


CHRONIC  ARTICULAR  OSTITIS  :   SYMPTOMATOLOGY.   253 

weeks  before  she  presented  for  admission.  The  lameness 
had  been  very  slight  and  unchanging  ;  there  had  not  been  a 
twinge  of  pain  in  any  part  of  the  limb,  and  never  any  night 
screams.  She  could  walk  long  distances  without  tiring.  As 
the  patient  stood  for  examination  the  right  limb  was  a  little 
everted.  The  usual  changes  in  the  contour  of  the  nates  exist- 
ed, and  on  passive  motion  some  resistance  was  encountered 
at  150°  in  extension,  and  135°  in  flexion.  The  other  move- 
ments, viz.,  abduction,  adduction,  and  rotation,  were  limited 
to  very  small  arcs.  I  failed  on  several  tests,  concussion  espe- 
cially, to  elicit  any  tenderness  in  or  about  the  joint.  The 
atrophy  of  the  thigh  was  three  quarters  of  an  inch,  and 
that  of  the  calf  a  half  inch.  The  diagnosis  was  made  with- 
out any  hesitation  and  the  lesion  was  located  in  the  upper 
epiphysis  of  the  femur.  During  the  first  week  of  Novem- 
ber she  became  very  lame  and  began  to  cry  out  at  night 
without  waking.  The  symptoms  did  not  yield  to  the  treat- 
ment employed,  and  a  month  afterwards  a  little  thickening 
about  the  trochanter  was  observed,  while  the  limb  was  as- 
suming a  degree  of  permanent  flexion.  In  other  words,  this 
case  was  passing  into  the  second  stage  at  the  close  of  what 
seemed  to  be-  the  first  exacerbation.  This  is  contrary  to 
rule. 

This  thickening  around  the  trochanter  proved  to  be  the 
early  appearance  of  an  abscess  which  was  quite  large  in 
February,  and  which  increased  to  a  great  size  by  the  latter 
part  of  May,  when  it  opened  spontaneously. 

The  opening  of  the  abscess  was  not  followed  by  any  con- 
stitutional reaction,  and  it  soon  closed  down  to  an  inoffen- 
sive sinus,  which  itself  closed  in  the  early  part  of  August, 
to  reopen  again,  however,  at  the  end  of  a  week.  The  gen- 
eral health  continued  good  all  the  while,  and  the  joint  sur- 
faces prior  to  this  time  had  not  suffered  from  the  disease. 
There  was  a  certain  outward  rotation  combined  with  the 
flexion,  giving  to  the  case  the  clinical  features  of  the  second 
stage.  The  subsequent  changes  were  slow  in  evolution. 
The  sinus  continued  to  discharge,  and  in  November,  a  year 
having  now  elapsed  since  the  first  signs  of  abscess,  there 
were  two  openings,  and  the  child  was  suffering  more  or  less 
from  pain  in  the  knee.  These  keen  pains  were  the  first  she 
had  ever  had,  and  they  were  peculiarly  distressing  and  did 
not  subside  until  the  first  week  in  December. 

In  the  following  spring,  an  improvement  was  apparent, 
the  sinus  closed,  and  when  she  was  discharged  the  right 


254  DISEASES  OF  THE  HIP. 

limb  was  flexed  at  an  angle  of  about  140°  and  rotated  in- 
ward over  a  small  arc.  There  were  two  inches  shortening 
and  the  limb  bore  the  weight  of  the  body  without  evidence 
of  tenderness. 

It  has  been  asserted  with  considerable  emphasis  by  some 
writers  that  the  knee  pain  is  not  present  in  this  stage  of  the 
disease.  My  own  experience  flatly  contradicts  the  state- 
ment. I  have  at  this  writing  under  treatment  one  of  the 
most  obstinate  cases  of  ill-defined  neuralgia  in  a  young  lady, 
the  subject  of  disease  at  the  hip  many  years  ago,  that  I  have 
ever  encountered.  The  deformity  is  characteristic,  and  the 
shortening  is  about  three  inches,  yet  she  walks  with  great 
ease  when  in  the  intervals  of  the  paroxysms.  The  anky- 
losis  seems  bony,  and  there  are  no  acute  symptoms  at  any 
time  save  these  frightful  neuralgias.  This,  however,  is  an 
exceptional  case  as  regards  the  acuteness  of  the  pain. 
Many  patients  who  go  for  years  with  profuse  suppuration, 
have  much  pain  on  the  appearance  of  a  new  abscess. 

The  text-books  illustrate  very  acurately  the  condition  of 
these  sufferers  in  this  stage,  and  the  graphic  accounts  of  ex- 
cision from  time  to  time  picture  but  too  faithfully  the  pa- 
tient prior  to  the  operation.  Figures  Nos.  25,  26,  and  27, 
represent  the  resulting  deformity  in  a  certain  type  of  cases. 

This  boy,  from  whom  the  photographs  were  taken,  I  saw 
first  in  May,  1873.  He  was  at  that  time  five  years  of  age, 
and  the  disease  had  already  advanced  into  the  second  stage. 
Ten  years  elapsed  before  I  saw  him  again.  Abscess  had 
formed  in  1874,  but  had  not  caused  much  annoyance.  A 
draining  sinus  a  few  months,  a  gradual  change  in  the 
position  of  the  limb,  and  an  occasional  pain  were  all  the 
data  I  could  get  out  of  his  history.  For  eight  years  he  had 
been  on  his  feet  every  day,  it  was  stated  to  me,  and 
he  only  thought  of  seeking  advice  now  because  of  pain 
about  his  hip  sufficiently  sharp  to  keep  him  awake  at 
night.  His  position  in  standing  can  well  be  seen  in  Fig.  25. 
While  the  gait  is  aught  but  graceful,  it  is  an  easy  one. 
The  shortening  as  measured  from  the  anterior  superior 
process  is  only  three  quarters  of  an  inch,  from  the  umbilicus 
it  is  three  and  a  quarter  inches,  while  there  is  none 
as  measured  from  the  tip  of  the  trochanter  to  the  external 
malleolus.  That  is  to  say,  the  shaft  of  the  bone  has  kept 
pace  in  growth  with  that  of  its  fellow.  The  thigh  in  cir- 
cumference is  three  inches  less  than  the  right,  the  knee  only 
a  half  inch,  and  the  calf  an  inch.  The  lordosis  is  well 


CHRONIC  ARTICULAR   OSTITIS  :   SYMPTOMATOLOGY.   255 


shown  in  Figs.  25 
and  26,  and  the  an- 
gle of  deformity,  in 
flexion  at  least,  in 
Fig.  27.  I  cannot 
get  any  motion  at 
the  hip.  The  photo- 
graphs were  taken 
in  April,  and  in  May 
the  cicatrix  on  the 
outer  side  of  the 
thigh  broke  down 
in  the  centre,  and  a 
discharge  there- 
from continued  un- 
til the  latter  part 
of  July.  At  pres- 
ent writing  the 
sinus  has  closed. 
In  a  large  number 
of  cases  the  anky- 
losis  is  not  bony, 
and  in  time  there  is 
indeed  an  astonish- 
ing degree  of  mo- 
tion. One  finds  at 
an  early  examina- 
tion the  hip  to  all 
appearance  firmly 
ankylosed,  and  at  a 
subsequent  exami- 
nation, especially  if 
several  years  have 
elapsed,  an  arc  of 
motion  that  is  sur- 
prising. I  have  had 
such  experience 
time  and  again,  and 
I  have  knowledge  of 
like  experience  with 
other  surgeons. 

To  recount,  then, 
the  clinical  feature 
of  the  third  stage. 

One     patient    will  FlG-  2S.-THE  USUAL  D.FORMIW  OF  THE  THIRE 

pass  almost  imper- 


256 


DISEASES  OF  THE  HIP. 


CHRONIC  ARTICULAR  OSTITIS :   SYMPTOMATOLOGY.    257 


258  DISEASES  OF  THE  HIP. 

ceptibly  from  the  second  to  the  third,  and  the  exacerbations 
will  be  infrequent  and  far  from  severe.  Abscess  may  form, 
and  in  some  instances  it  will  not  ope-n,  but  the  sac  will 
collapse,  the  fluid  contents  disappear,  and  the  caseous  de- 
tritus remain  an  encapsulated  and  an  inoffensive  product. 

This  case  is  one  of  many  whose  details  are  not  only  famil- 
iar to  me,  but  whose  notes  are  in  my  possession.  A  little 
girl  six  years  of  age  was  admitted  to  hospital  about  Christ- 
mas, 1875;  her  sign  of  disease  appeared  five  months  before, 
and  she  had  passed  through  one  or  two  exacerbations.  The 
case  was  slowly  passing  from  the  first  into  the  second  stage. 
A  few  pains  at  odd  intervals  were  all  the  symptoms  noted 
between  her  admission  and  the  middle  of  October,  1876, 
when  record  is  made  of  a  diffuse  swelling  in  the  upper  third 
of  the  thigh,  outer  aspect.  Her  lameness  was  much  more 
marked.  The  fulness  did  not  develop  into  a  well-defined 
tumor  with  marked  fluctuation  until  the  latter  part  of  May, 
1877.  It  did  not  go  on  to  suppuration,  but  remained  in  statu 
quo  for  about  a  year,  and  then  began  to  disappear.  In  July, 
1879,  the  remark  was  made  on  the  records  that  there  had 
been  for  many  months  no  changes  worthy  of  note.  The 
tumor  had  collapsed,  the  lordosis  was  very  marked,  the  tro- 
chanter  was  prominent,  the  thigh  was  limited  in  extension 
to  140°,  and  was  rotated  outward  over  a  small  arc.  There 
was  motion  over  an  arc  of  twenty  degrees,  and  while  mov- 
ing the  thigh  a  grating  sensation  in  the  joint  was  imparted 
to  my  hand  as  it  rested  over  the  hip.  Abduction  and  rota- 
tion were  not  permitted,  and  the  limb  was  shortened  one 
inch  really,  one  and  a  half  inches  practically.  In  other 
words,  the  abscess  sac  had  formed  and  had  disappeared 
without  external  opening,  and  the  limb  was  shortened  by 
bony  changes,  and  was  rotated  outwards.  She  had  long 
since  been  discharged  from  the  hospital,  as  she  walked  very 
easily  and  was  free  from  pain. 

In  August,  1881,  she  had  an  exacerbation  lasting  about 
two  weeks,  but  the  abscess  sac  did  not  refill.  I  traced  out 
the  case  in  March  of  present  year,  and  found  the  signs  as 
follows:  the  angle  of  flexion  was  120°,  and  the  limb  was 
rotated  inward  a  little;  the  real  shortening  was  the  same, 
while  the  practical  was  two  and  a  half  inches  greater  (four 
inches  now);  the  arc  of  motion  was  scarcely  appreciable, 
but  the  lumbar  spine  was  very  flexible,  and  hence  her  facility 
in  getting  about;  the  sac  was  still  in  a  state  of  collapse,  and 
it  had  never  refilled. 


CHRONIC  ARTICULAR  OSTITIS  :   SYMPTOMATOLOGY.   259 

It  need  not  be  a  necessary  part  of  the  clinical  history  to 
have  external  suppuration,  even  if  a  residual  abscess  do 
appear. 

There  is  another  patient  whose  hip  suppurates  freely, 
hectic  comes  on  from  time  to  time,  regulated  very  accurately 
by  the  invasion  of  pus  tracks  into  fresh  tissues,  the  health 
fails  rapidly,  and  locomotion  is  impossible.  By  day  the 
sufferer  sits  in  a  chair  with  the  diseased  limb  swinging 
scissors-like  over  the  other,  ready  with  the  hand  to  steady 
the  member  when  it  is  necessary  to  move  about  or  to  grasp 
it  on  the  recurrence  of  any  pain.  The  knowledge  has  come 
by  experience  that  fixation  of  the  hip  or  pressure  over  the 
neuralgic  areas  will  relieve  pain.  Day  in  and  day  out  the 
child  will  sit  in  this  position  nursing  the  limb,  and  yet 
showing  a  patience  that  would  bring  the  blush  to  a  martyr. 
In  bed  the  dorsal  decubitus  is  assumed  for  a  while  with 
both  thighs  flexed;  the  sound  one  at  a  right  angle  acting 
as  a  frame  for  the  bed-clothing,  the  diseased  one  at  an 
acute  angle  and  generally  rotated  inward,  the  hands  clasp- 
ing the  thigh  or  the  leg,  zealously  guarding  the  crippled 
member.  Frequently  a  pillow  will  have  been  placed  be- 
tween the  knees,  so  that  when  the  weary  one  dozes  off  to 
sleep  fear  of  a  fall  need  not  be  entertained.  The  hands  re- 
lax their  grasp  then,  and  the  pillow  suffices.  A  little  later 
he  manages  to  get  over  on  the  sound  side,  while  the  dis- 
eased limb  rests  in  flexion  and  inward  rotation  on  a  pillow 
or  an  air-cushion  which  lies  upon  the  fellow-limb.  Ulcers 
are  raw,  surrounding  parts  are  tense  and  painful,  the  sleep 
is  broken  often  through  the  night,  and  the  morning  comes 
with  a  sense  of  relief;  and  so  it  goes  through  one  ex- 
acerbation and  then  the  interval  of  comparative  comfort. 
It  is  true  here,  as  in  the  other  stages,  that  every  exacer- 
bation leaves  the  patient  a  little  worse.  Finally,  these  run 
one  into  the  other  as  the  end  draws  nigh,  the  emaciation 
reaches  its  limit,  so  that  one  can  truthfully  say  there's  noth- 
ing here  but  skin  and  bones  and  impending  death. 

Some,  as  I  had  occasion  to  remark  in  another  part  of  this 
chapter,  get  well  after  such  suffering  and  such  profuse  sup- 
puration. 

The  duration  of  the  third  stage  varies  between  a  few 
months  and  a  number  of  years.  The  majority  of  cases 
terminating  in  a  useful  limb  will  average  about  three  years, 
/'.<?.,  the  sinuses  close,  the  exacerbations  seem  to  be  at  an  end, 
and  the  patient  is  able  to  walk  without  support  I  would 


200  DISEASES  OF  THE  HIP. 

have  it  understood  that  I  am  not  speaking  now  from  statis- 
tics. This  is  not  a  statistical  chapter.  The  proneness  of 
sinuses  to  reopen,  the  difficulty  attending  the  elimination 
of  necrotic  pieces  of  bone,  and  the  interference  with  repair- 
ing bone  tissue  by  attempts  at  walking,  render  statistics  of 
cured  cases  very  difficult  to  obtain. 

Concerning  the  duration  of  the  third  stage,  we  can  draw 
conclusions  that  merely  approximate  the  reliable,  from 
patients  that  are  still  living.  In  looking  over  the  names  of 
patients  whose  cases  I  analyzed  for  publication  in  1878,  I 
find  that  some  have  relapsed,  others  I  have  not  seen.  One 
relapsed  after  ten  years'  immunity  from  abscesses  or  incon- 
venience of  any  kind.  He  is  now  in  feeble  health  and  has 
one  or  two  open  sinuses,  with  pains  in  the  thigh  and  at  the 
knee. 

One  frequently  takes  it  for  granted  that,  because  a 
patient  does  not  return  for  treatment,  he  has  continued 
well.  Patients  with  chronic  disease  as  a  rule  do  not  remain 
long  under  the  same  surgeon.  It  matters  little  how  much 
they  may  be  impressed  with  the  skill  of  their  medical  at- 
tendant, they  are  easily  induced  by  friends  to  seek  other 
advice. 

I  have,  therefore,  in  the  present  volume,  been  unable  to 
secure  reliable  data  of  a  sufficiently  large  number  of  cases 
to  make  statistics  on  this  head  of  any  positive  value.  I  have 
learned  that  it  is  very  unsafe  to  prognosticate  that  there 
will  be  no  recurrence  of  symptoms,  no  re-opening  of 
sinuses,  no  future  abcess  in  cases  that  seem  to  be  examples 
even,  of  a  caries  sicca. 

This  is  true,  however,  that  in  many  instances  the  late  ex- 
cerbations  are  induced  by  some  traumatic  influence  and  per- 
tain purely  to  the  periarticular  structures.  They  are 
necessarily  mild,  subside  without  treatment,  and  often  do 
not  come  under  medical  or  surgical  inspection.  I  have  seen 
very  frequently  such  cases  come  under  a  surgeon's  care  and 
be  subject  to  all  the  paraphernalia  of  joint  therapeutics 
that  a  case  in  the  early  stages  would  demand.  Treatment 
seems  to  begin  really  at  this  late  day,  and  then  the  patient 
must  go  through  the  stereotyped  course,  the  early  subsi- 
dence of  symptoms  being  attributed  to  the  measures 
employed. 

COMPLICATIONS. — Among'  the  direct  complications  in  the 
early  stage  is  a  dorsal  dislocation.  This  is  not  of  common 
occurrence.  I  have  seen  two  cases,  and  have  placed  one  on 


CHRONIC  ARTICULAR  OSTITIS  :   SYMPTOMATOLOGY.   26 1 

record  in  the  American  Journal  of  the  Medical  Sciences.  It 
was  in  a  girl  who  began  to  walk  lame  in  the  spring  of  1877. 
Her  lameness  was  followed  within  a  month  by  the  first  ex- 
acerbation of  pain.  This  subsided  spontaneously,  and  the 
relief  was  so  complete  that  in  October  of  the  same  year 
not  even  a  limp  could  be  detected.  The  signs  in  the  inter- 
val between  August  and  October  had  been  unequivocal.  In 
the  beginning  of  the  next  February  she  had  scarlatina, 
followed  by  enlargment  of  the  cervical  glands,  and  in  March 
a  second  exacerbation  of  hip  symptoms  appeared.  These 
were  so  acute  that  the  signs  at  the  close  of  the  second  week 
in  March  were  those  of  the  second  stage.  The  thigh  was 
held  flexed  at  90°,  and  in  marked  outward  rotation.  The 
promptness  with  which  relief  followed  made  it  clear  that 
the  second  stage  had  not  been  reached.  The  signs  in  the 
next  fortnight  became  those  of  the  first  stage,  and  while  this 
remission  was  of  longer  duration  than  the  preceeding  it 
was  not  so  complete;  for  the  resistance  to  flexion  persisted, 
and  the  child  was  never  without  a  trace,  at  least,  of  lameness. 

In  March  of  the  following  year  (1879),  she,  with  her  play- 
fellows, caught  the  "walking  fever"  (it  was  very  prevalent 
at  this  time),  and  after  one  of  these  feats  she  grew  suddenly 
very  lame,  and  the  third  exacerbation,  milder  in  type  than 
the  second,  declared  itself ;  but  the  symptoms  disappeared 
under  rest  within  a  week.  From  general  appearances  in 
May,  two  months  subsequently,  one  would  declare  that  she 
had  no  disease,  so  actively  did  she  move  about.  One  day 
during  the  last  week  of  this  month  a  member  of  the  staff 
observed  a  shortening  of  the  limb,  and  a  refusal  on  the  part 
of  the  child  to  walk.  Dr.  Knight's  attention  was  called  to 
the  case,  and  an  examination  revealed  an  unmistakable  dis- 
location on  the  dorsum  ilii.  The  limb  was  shortened  one 
inch,  was  apparently  much  shorter  than  this,  the  thigh  was 
semi-flexed,  rotated  inward,  and  adducted.  A  few  days  be- 
fore this  the  limbs  were  of  equal  length,  and  were  free  from 
any  deformity.  The  child  reported  that  she  fell  out  of  her 
bed  a  night  or  two  previously,  but  on  a  careful  investiga- 
tion, this  was  found  improbable:  the  beds  in  the  dormitory 
are  so  close  one  to  the  other,  that  a  child  could  not  fall  be- 
tween them.  Furthermore,  on  questioning  both  the  day 
nurse  and  the  night  nurse,  as  well  as  the  children  who  sleep 
contiguous,  no  one  saw  her  fall  from  the  bed,  and  all  are 
positive  that  she  did  not. 

I  was  in  the  country  at  this  time,  and  as  I  was  expected 


262  DISEASES  OF  THE  HIP. 

home  every  day  the  reduction  was  postponed  until  my  re- 
turn. 

Chloroform  was  administered  four  days  after  the  accident 
and  the  diagnosis  was  fully  confirmed.  After  a  few  minutes 
manipulation,  the  head  of  the  femur  slipped  into  place  with- 
out any  "  click."  Measurement  was  made,  and  limbs  found 
equal  in  length.  While  applying  a  roller  about  the  hips, 
the  head  of  the  bone  slipped  again  but  was  easily  replaced. 
No  grating  could  be  felt.  Extension  by  weight  was  made, 
and  during  the  day  she  suffered  considerable  pain  in  par- 
oxysms. 

The  limb  remained  in  position  next  day,  though  the  child 
required  an  opiate  to  secure  rest  through  the  night. 

Extension  was  removed  two  days  later  and  a  firm  spica 
was  applied  with  a  pad  above  the  trochanter,  and  child  was 
carefully  placed  in  a  rolling  chair. 

The  following  record  was  made  two  weeks  after  the  re- 
duction of  the  deformity:  Since  date  of  last  note  the  case 
has  progressed  as  well  as  we  could  expect.  The  dressings 
have  been  carefully  removed  and  reapplied  every  other  day 
to  avoid  excoriations.  Any  movements  at  the  joint  have 
caused  the  child  to  scream  aloud.  This  noon  while  passing 
through  the  ward,  I  observed  the  limb  sharply  flexed,  ad- 
ducted,  and  rotated  inward,  along  with  a  marked  degree  of 
shortening.  An  anaesthetic  was  administered,  and  I  could 
feel  the  head  of  the  bone  distinctly  on  the  dorsum,  and 
made  out  one  and  a  half  inches  shortening.  It  was  easily  re- 
duced and  child  placed  in  bed  with  usual  precautions. 

Next  morning  the  hip  was  dislocated  again.  Dr.  Ap.  M. 
Vance,  a  member  of  the  staff,  made  a  splint  of  Manilla 
paper  and  glue  in  the  same  manner  as  he  makes  his  spinal 
jackets.  He  procured  his  cast  from  a  boy  whose  limb  was 
equal  in  length  and  size  to  our  patient's,  and  the  whole 
dressing  dried  and  was  ready  for  application  next  day. 

After  reduction  had  been  made  it  grasped  the  pelvis  in 
a  broad  band,  and  completely  encased  thigh  and  knee  and 
was  held  securely  by  a  lacing  in  front  throughout  the  whole 
length. 

We  had  no  difficulty  with  the  limb  after  the  paper  splint 
was  applied.  The  child  moved  about  now  quite  freely  by 
aid  of  a  chair. 

A  month  elapsed  and  it  was  noted  that  the  limb  was 
equal  in  length  with  its  fellow.  No  deformity,  child  free 
from  pain,  and  case  in  every  way  doing  well. 


CHRONIC  ARTICULAR   OSTITIS  :   SYMPTOMATOLOGY.   263 

In  August  a  leather  splint  was  substituted  for  the  paper, 
and  on  testing  the  joint  as  to  motion,  muscular  resistance 
was  offered  at  every  turn.  The  disease  was  slowly  passing 
into  the  second  stage  without  the  pretext  of  an  exacerba- 
tion. In  December  I  was  sanguine  enough  to  hope  that 
the  removal  of  the  splint  and  the  employment  of  passive 
motion  would  restore  the  joint  functions.  The  pelvis  was 
raised  on  the  left,  the  diseased  side,  and  comparative 
measurements  from  the  anterior  superior  spinous  process 
to  the  lower  border  of  the  internal  malleolus  showed 
there  was  no  real  shortening,  while  from  the  umbillicus  to 
the  malleoli  they  showed  a  practical  shortening  of  one  inch. 
The  thigh  in  its  upper  third  was  one  and  a  half  inches 
smaller  than  its  fellow,  and  the  calf  three  quarters  of  an 
inch  smaller  than  the  right.  It  was  difficult  to  satisfy  my- 
self that  any  motion  at  the  joint  existed. 

I  soon  had  to  abandon  the  idea  that  this  was  an  ordinary 
dislocation,  and  to  accept  the  situation,  viz.,  that  I  had  a 
well-marked  case  of  progressive  chronic  articular  ostitis  to 
deal  with,  and  that  the  dislocation  was  but  an  incident  in  its 
march,  permitted  by  a  ligamentum  teres  that  had  suffered  in 
nutrition  from  a  caseous  ostitis  in  close  proximity  to  one 
or  the  other  extremity.  I  could  not  get  any  passive  motion, 
and  soon  desisted.  The  atrophy  reached  two  inches  in 
thigh  circumference  by  the  following  April,  and  since  then 
has  remained  in  statu  quo.  The  real  shortening  at  this  time 
was  a  half-inch,  and  was  three  quarters  of  an  inch  a  year  later. 
In.  April,  and  in  November,  1882,  it  was  one  inch,  while  the 
practical  shortening  was  two  inches.  There  was  an  abscess 
of  three  or  four  weeks'  standing  on  the  anterior  surface  of 
the  thigh  outer  aspect.  In  December  she  was  scarcely  able 
to  walk.  Quite  recently  I  have  found  the  patient  walking 
very  fairly.  The  shortening  has  increased,  and  the  abscess 
sac  has  collapsed. 

Mr.  Hilton  (Lancet  vol.  ii,  1868,  p.  2)  reports  a  case  where- 
in the  dislocation  occurred  just  as  the  patient  was  falling 
asleep;  and,  commenting  on  this,  he  says  ("  Lectures  on 
Rest  and  Pain"):  "  Here  I  think  it  worthy  of  a  passing  con- 
sideration to  inquire  why  it  is  that  these  dislocations  almost 
always  occur  just  as  the  patient  is  falling  off  to  sleep.  It 
is  then  that  volition  has  withdrawn  its  influence  from  the 
nervous  system  generally,  and  the  excito-motor  function  of 
the  spinal  cord  seems  to  obtain  an  exclusive  authority  over 


264  DISEASES  OF  THE  HIP. 

the  limbs,  and  produces  the  involuntary  spasmodic  condition 
of  the  muscles  which  causes  these  displacements." 

In  the  spring  of  1879  I  found,  on  examining  a  child  with 
chronic  ostitis  of  the  acetabulum,  that  the  head  of  the  bone 
slipped  out  of  the  cavity  very  readily,  and  the  nurse,  a  few 
days  previously,  in  dressing  the  patient  one  morning,  felt  a 
peculiar  slipping  at  the  joint,  and  feared  that  the  hip  had 
become  dislocated.  The  autopsy,  a  few  weeks  later,  re- 
vealed a  carious  condition  of  the  floor  of  the  acetabulum 
and  the  destruction  of  the  ligamentum  teres.  The  infre- 
quency  of  such  dislocations  in  the  early  stage,  taken  in  con- 
nection with  the  frequency  of  examinations,  with  and  with- 
out anaesthetic,  furnishes,  to  my  mind,  strong  evidence 
against  the  pathology  as  taught  by  Dr.  Sayre  and  his 
followers. 

In  the  third  stage  dislocations  are  occasionally  found,  but 
they  do  not  occur  with  nearly  the  frequency  they  were  sup- 
posed to  occur  prior  to  1853,  when  Dr.  March  presented  a 
paper  before  the  American  Medical  Association,  protesting 
against  calling  such  those  cases  in  which  pathological 
changes  had  taken  place  between  the  diaphysis  and  the 
epiphysis,  or  in  which  the  head  and  neck  were  destroyed, 
while  the  trochanter  occupied  a  position  above  Nelaton's 
line. 

The  frequency  with  which  tubercular  meningitis  develops 
in  the  early  stages  of  this  disease  suggests  at  times  a  pos- 
sible connection  as  a  complication,  yet  it  is  only  necessary 
to  mention  the  fact  that  it  does  occur,  and  the  relationship 
I  have  regarded  as  more  of  the  nature  of  cause  and  effect. 
That  is  to  say,  I  am  of  the  opinion  (the  opinion  is  not  forti- 
fied, however,  by  strong  evidence)  that  the  meningitis  is 
caused  by  either  the  irritation  induced  by  the  frequently- 
recurring  paroxysms  of  pain,  or  by  the  suppurating  foci  in 
the  well-known  manner.  It  must  be  understood,  though, 
that  I  am  speaking  now  of  exciting  causes,  and  that  an  here- 
ditary tuberculous  diathesis  must  be  present.  And  I  do 
not  wish  to  go  on  record  as  asserting  that  tubercular 
meningitis  occurs  only  in  the  early  stage  of  chronic  articular 
ostitis.  It  does  arise  in  the  advanced  stages;  but  my  own 
observation  leads  me  to  infer  that  it  is  a  more  frequent  ac- 
companiment of  the  early  stage. 

The  displacements  that  occur  in  the  third  stage  are  va- 
ried. The  disintegration  of  the  head  and  the  fusion  of  the 
eroded  proximal  end  of  the  femur  with  a  carious  rim  of  the 


CHRONIC  ARTICULAR  OSTITIS  :   SYMPTOMATOLOGY.   265 

acetabulum  serve  to  perpetuate  a  very  awkward  deformity 
H.nless  corrected  by  surgical  means. 

Dislocation  on  the  dorsum  is  seldom  a  dislocation  with 
the  head  and  neck  intact.  There  is  nearly  always  change 
in  the  angle  with  which  the  neck  is  joined  to  the  shaft,  and 
in  proportion  to  the  amount  of  bone  left  in  the  epiphysis, 
so  much  the  greater  will  be  the  deformity.  Last  spring, 
while  tracing  out  cases  of  interest,  I  found  a  boy  in  the 
fourth  ward,  seventeen  years  of  age,  with  a  most  ungainly 
deformity  of  the  hip.  The  angle  at  which  the  thigh  was 
held  flexed  was  110°,  the  adduction  was  very  sharp,  and 
the  trochanter  stood  out  on  a  plane  of  two  inches,  at  least, 
from  the  plane  of  the  body.  At  the  same  time  an  irregular 
bony  mass  could  be  felt  lying  above  the  acetabulum  or  in 
close  proximity  with  its  rim,  and  connected  with  the  shaft 
below  the  trochanter.  Abduction  and  outward  rotation 
were  quite  impossible.  There  were  two  and  a  half  inches 
real  shortening  and  three  inches  practical.  It  was  very  evi- 
dent from  the  condition  of  the  cicatrices  and  from  the 
absence  of  inflammatory  products  in  the  soft  parts,  that  the 
disease  was  fully  arrested.  He  had  motion  over  an  arc  of 
ten  or  fifteen  degrees,  the  lumbar  spine  was  exceeding 
flexible,  and  his  gait,  though  awkward,  was  really  a  good 
one.  The  abdomen  was  not  enlarged,  and  the  boy  seemed 
to  be  in  good  health.  The  limb  was  not  oedematous. 

When  I  had  last  seen  him  it  was  in  October,  1878.  He 
had  then  a  moderate  hydro-peritoneum  and  oedema  of  the 
scrotum;  the  urine  contained  granular,  fat  and  hyaline 
casts,  its  specific  gravity  was  1012,  and  it  contained  about 
twenty  per  cent  of  albumen.  There  was  extensive  ulcera- 
tion  about  the  hip,  and  the  prognosis,  as  given  then,  was 
very  grave,  especially  as  the  last  abscess  opened  in  the  peri- 
neum. There  was  no  dislocation  at  this  time.  In  this  long 
interval  he  had  not  received  any  treatment,  but  had  simply 
led  a  vegetative  kind  of  existence  in  the  upper  rooms  of  a 
huge  tenement-house,  and  Nature  had  succeeded  in  effect- 
ing a  recovery  by  thus  removing  the  head  from  the  aceta- 
bulum. That  this  portion  of  the  pelvis  had  been  perforated 
the  perineal  abscess  attested;  and  the  evidences,  although 
I  could  not  make  out  an  enlarged  liver  in  1878,  were 
strongly  in  favor  of  lardaceous  degeneration  having  already 
begun. 

With  such  extensive  suppuration  as  one  often  encounters, 
it  would  naturally  be  supposed  that  ulceration  of  the  walls 


266  DISEASES  OF  THE  HIP. 

of  arteries  in  the  vicinity  of  the  hip  would  often  occur. 
Such  cases  are  on  record,  but  this  complication  is  of  very 
infrequent  occurrence.  I  find  only  one  case  among  my 
notes,  and  this  was  in  a  boy  who  contracted  disease  at  his 
hip  when  three  years  of  age.  He  was  five  when  the  second 
stage  was  reached,  and  six  when  signs  of  the  third  were  re- 
cognized. The  suppuration  in  the  early  part  of  the  third 
stage  was  very  profuse,  and  he  made  a  narrow  escape  with 
his  life.  After  a  year  or  two  he  was  in  such  condition  that 
a  good  limb  was  prognosticated.  Three  years  then  elapsed, 
in  which  interval  he  was  regarded  as  cured.  The  deformity 
was  very  objectionable,  however,  and  finally  means  were 
employed  to  reduce  this  to  the  minimum.  He  wore  appa- 
ratus six  months,  when  an  exacerbation  came  on,  the  old 
abscess  sac  refilled,  other  abscesses  followed,  and  suppura- 
tion continued  uninterruptedly  for  sixteen  months,  when  he 
died  of  exhaustion.  Five  days  before  death,  violent  arterial 
haemorrhage  from  the  bottom  of  a  deep  ulcer  on  the  inner 
side  of  the  thigh  came  on  suddenly  one  evening,  and  it  was 
necessary  to  apply  a  tourniquet  to  control  it.  The  vessel 
from  whence  the  blood  came  was  a  branch  of  the  profunda 
artery,  and  on  the  following  day  a  second  haemorrhage 
occurred,  more  difficult  to  control.  Two  hours  later  a  third, 
which  ceased  on  the  application  of  a  compress. 

One  of  the  most  formidable  complications,  or  rather 
sequels,  is  lardaceous  degeneration.  The  first  symptom  of 
this  is  pain  in  the  right  hypogastrium.  The  seat  of  pain  is 
presumably  the  liver;  and  this  is  a  very  constant  symptom. 
Whenever  I  find  a  child  with  a  suppurating  bone-disease 
locating  the  pain  under  the  border  of  the  free-ribs,  I  forth- 
with examine  the  urine  and  find  invariably  a  low  specific, 
gravity  and  a  pale  color.  Albumen  may  not  appear  for 
several  months. 

In  the  case  of  a  boy,  who  died  in  April  last,  I  began  ex- 
amining his  urine  in  October,  1881,  finding  the  specific 
gravity  at  that  time  1004,  and  not  finding  a  trace  of  albu- 
men. In  November  of  the  same  year  it  was  1003.  In  May, 
1882,  it  was  1007,  and  although  the  liver  dulness  extended 
full  five  fingers'  breadth  below  the  free-ribs,  there  was  no 
albumen.  It  was  not  until  the  month  of  July,  two  months 
later,  that  I  succeeded  in  getting  the  first  trace  of  albumen. 
It  will  thus  be  seen  that  fully  seven  months  elapsed  between 
the  first  symptoms  of  lardaceous  disease  and  the  presence  of 
albumen  in  the  urine. 


CHRONIC  ARTICULAR  OSTITIS :  SYMPTOMATOLOGY.    267 

I  have  long  since  reached  the  conclusion  that  lardaceous 
disease  need  not  be  feared  in  children  whose  family  histories 
are  free  of  tuberculosis.  I  am  unwilling,  as  yet,  to  change 
my  views  on  this  subject,  inasmuch  as  in  several  of  my 
Cases  I  have  not  been  able  to  get  any  data  in  connection 
with  the  family  history.  Dr.  Poore  (Medical  Record,  vol. 
xv.,  p.  101)  has  reached,  practically,  the  same  conclusion. 
The  last  case  but  two  that  I  have  reported  furnishes  testi- 
mony to  a  very  interesting  point  in  connection  with  this 
subject,  viz.,  the  curability  of  this  constitutional  disease. 
This  is  the  first  case  I  have  found  in  my  clinical  researches 
wherein  lardaceous  disease  has  presumptively  undergone  re- 
solution without  surgical  interference  with  the  bone-disease. 
I  know  as  a  fact  that  it  does  subside  in  a  few  cases  in  which 
removal  of  the  diseased  bone  has  been  effected. 

From  the  beginning  of  these  changes  to  the  final  termin- 
ation in. death,  the  time  yaries  remarkably — often  it  extends 
over  a  number  of  years.  I  saw,  only  this  last  spring,  a  boy 
die  from  lardaceous  disease  who  had  been  a  victim,  to  my 
positive  knowledge,  for  ten  years.  Year  after  year  I  have 
treated  him  in  exacerbation,  of  chronic  nephritis  during 
that  whole  period. 

The  course  of  this  disease,  like  that  of  the  disease  which 
at  follows,  is  marked  by  exacerbations.  The  deformities  of 
Ihe  spine  are  generally  compensatory,  and  I  do  not  attach 
much  importance  to  the  lumbar  lordosis.  I  do  not  recall 
any  case  of  permanent  lateral  curvature  or  any  rotary  cur- 
vature developing  out  of  this  compensatory  curve.  The 
pelvic  deformities  are  the  more  annoying  when  they  do 
occur,  and  the  interference  with  sexual  relations  becomes  a 
serious  complication,  which  calls  the  more  strenuously  for 
measures  preventive  of  such  deformity.  I  have  seen  a  case 
in  a  woman  with  the  deformity  of  the  thigh  so  strongly 
adducted  that  laparotomy  was  performed  to  effect  delivery 
of  a  fetus. 

The  influence  of  the  exanthemata  in  this  disease  is  well 
recognized,  and  I  have  already  dwelt  upon  these  sufficiently 
long  in  Chapter  IX. 


CHAPTER  XIV. 

CHRONIC  ARTICULAR  OSTITIS  OF  THE  HIP. 

DIAGNOSIS. 
PART  I. — THE  FIRST  STAGE. 

There  is  a  large  class  of  men  both  in  the  profession  and 
out  of  the  profession  that  cares  little,  as  a  rule,  for  the  diag- 
nosis of  disease.  Such  men  are  saying  all  the  while,  "  Tell 
us  how  to  cure  diseases;  we  don't  care  any  thing  about  diag- 
nosis." In  the  ordinary  ills  of  life,  especially  those  whose 
course  is  rapid,  it  sometimes  does  seem  that  diagnosis  is 
of  no  value.  And  even  in  chronic  diseases  it  seems  some- 
times that  treatment  is  the  only  thing  worth  knowing. 

It  has  been  my  pleasure  during  the  past  decade  to  note 
the  interest  nearly  all  men  take  in  the  diagnosis  of  diseases 
in  the  neighborhood  of  the  hip.  The  first  thing,  as  a  rule, 
the  parent  wants  to  know  about  a  limping  child  is  whether 
it  has  "  the  hip-disease"  or  not,  and  it  is  seldom  that  the 
parent  will  rest  satisfied  with  the  opinion  of  a  single  prac- 
titioner. More  advice  is  sought,  and  this  question  must  be 
settled.  The  next  qustion  is,  What  was  the  cause  of  it? 

Somehow  the  impression  is  deeply  rooted  in  the  mind 
of  the  laity  that  "hip-disease'''  and  "white-swelling,"  and 
"  Pott's  disease,"  are  practically  incurable  diseases,  and  it 
makes  little  difference  how  many  flaming  circulars  are  sent 
about  the  country  by  travelling  quack  combinations,  certi- 
fying to  marvellous  cures;  how  many  shrines  exist  at  home 
and  abroad  where  the  magic  touch  heals  by  miracle;  how 
many  "natural  bone-setters,"  native  and  foreign,  fasten 
themselves  on  a  community;  how  many  scientific  pamphlets 
setting  forth  the  value  of  certain  splints  and  modifications  of 
splints  are  scattered  broadcast  over  the  medical  world — it 
matters  little,  I  say,  how  much  of  such  testimony  is  furnished 
in  favor  of  perfect  cures,  the  impression  still  remains 
that  these  diseases  rarely  leave  one  perfect  in  body  and 
limb.  The  lay  mind  soon  settles  down  to  the  acceptance  of 
the  inevitable,  and  it  wants  to  find  that  treatment  which 
will  bring  about  the  best  possible  results. 


CHRONIC  ARTICULAR  OSTITIS  :  DIAGNOSIS.       269 

Above  all  things  it  wants  to  know  what  is  the  matter. 
Not  only  does  the  layman  desire  this  knowledge,  but  the 
medical  man  hungers  after  diagnosis  in  diseases  about  the 
large  joints.  To  him  who  "  invariably  gets  good  results" 
diagnosis  is  the  last  knowledge  that  is  desirable.  He  likes 
such  vague  terms  as  "hip-disease,"  "morbus  coxae,"  etc. 
He  can  call  most  any  lesion  in  the  neighborhood  of  the  hip 
by  those  names,  and  in  many  cases  will  get  fair  results. 
But  to  him  who  signally  fails  time  and  again  in  getting  the 
good  results  claimed  for  this  treatment  and  that,  who  finds 
some  of  his  cases  going  on  to  deformity  and  shortening,  to 
profuse  suppuration  and  lardaceous  degeneration,  to  that 
man  diagnosis  is  valuable,  and  he  grows  weary  of  and  dis- 
gusted with  the  terms  whose  import  is  so  vague,  and  strives 
after  refinements.  He  is  keen  to  know  what  tissues  are  pri- 
marily involved;  he  wants  to  put  his  finger  on  the  initial 
pathological  process. 

Orthopedic  surgery  has  certainly  made  rapid  strides  in 
therapeutics,  and  while  much  of  the  value  of  any  therapeu- 
tical measure  depends  on  the  diagnosis  made,  there  is  still 
that  uncertainty  overhanging  this  subject  that  must  be  re- 
moved. The  general  surgeon  who  gets  the  case  late  gets 
it  when  all  the  tissues,  intra-  and  extra-articular,  are  involved 
and  places  little  value  on  an  anatomical  diagsosis.  He 
rightly  says  it  makes  little  difference  whether  the  disease  was 
central  or  peripheral,  whether  it  was  synovial  or  osseous:  the 
facts  as  shown  under  his  scalpel  are  that  all  the  structures 
are  involved.  Let  him,  however,  get  the  case  early,  when 
he  dares  not  employ  his  knife,  then  he  would  like  to  know 
just  what  tissues  are  involved.  He  doesn't  find  the  whole 
hip  infiltrated  and  disorganized,  but  finds  the  sott  parts 
around  the  joint  free  of  any  inflammatory  products.  It  is 
certainly  valuable  to  know  whether,  in  a  given  case,  when 
the  signs  are  yet  obscure  and  of  recent  date,  the  lesion  is  in 
the  centre  of  the  epiphysis,  in  the  acetabulum,  in  the  syn- 
ovial membrane,  in  the  periosteum,  in  the  periarticular  soft 
structures.  Is  this  knowledge  attainable?  Has  a  central 
ostitis  of  the  proximal  end  of  the  femur  symptoms  and 
signs  peculiar  to  itself;  has  an  ostitis  of  the  acetabulum  its 
own  signs  and  symptoms;  and  is  the  same  true  of  a  syno- 
vitis? 

The  importance  and  the  possibility  of  determining  the 
primary  lesion  in  joint  disease  are  receiving  much  con- 
sideration in  England.  At  the  last  meeting  of  the  British 


270  DISEASES  OF  THE  HIP. 

Medical  Association  several  valuable  papers  were  presented 
bearing  directly  on  these  points.  Mr.  George  Arthur 
Wright,  in  an  exceedingly  interesting  paper,  published  in 
the  British  Medical  Journal  for  September  ist,  1883,  uses 
the  following  language,  and  I  am  quite  sure  it  reflects  the 
views  of  the  majority  of  British  and  Continental  observers: 

"  I  would  further  suggest  that  this  question  of  the  seat 
of  the  primary  lesion  is  not  given  the  prominence  it  deserves, 
considering  its  importance  as  a  guide  to  treatment.  There 
is,  I  cannot  help  thinking,  too  much  tendency  to  lump 
•diseases  together  as  chronic  arthritis  of  this  or  that  joint." 

Frequently  I  have  heard  good  diagnosticians  after  ana- 
lyzing a  case,  thus  express  themselves,  "  This  is  bone- 
•disease."  I  do  not  remember  to  have  heard  any  one  con- 
vinced himself  as  to  whether  the  ostitis  is  in  the  epiphysis 
•.solely,  or  in  the  diaphysis,  or  in  the  acetabulum. 

The  truth  is  that  the  centres  of  ossification  in  the  diaphy- 
so-epiphysial  portion  of  the  femur  are  so  intimately  asso- 
ciated, anatomically  and  physiologically,  that  lesions  are 
very  prone  to  develop  in  two  or  more  of  these  centers  at 
very  nearly  the  same  time.  It  is  furthermore  true  that  for 
clinical  purposes  a  differentiation  is  undesirable. 

If  one  could  feel  reasonably  sure  that  the  inflammatory 
process  extended  through  the  lines  of  cartilaginous  union 
even,  it  would  be  just  as  easy  to  reach  the  parts  through 
the  trochanter  as  if  the  process  were  limited  to  one  or  the 
other  side  of  the  line.  In  a  chronic  ostitis  symptoms  are 
very  scarce  in  the  early  stages.  We  must  rely  more  on  cer- 
tain signs,  which  are  quite  constant.  Acute  synovitis  is 
marked  by  acute  symptoms  almost  from  the  very  beginning, 
such  as  pain,  extreme  tenderness  and  constitutional  disturb- 
ances generally.  The  signs,  too,  accompany  the  symptoms, 
and  become  quite  characteristic,  provided  the  lesion  be 
severe. 

The  symptoms,  then,  on  which  one  can  rely  in  diagnosti- 
cating a  chronic  articular  ostitis  of  the  hip  make  their  ap- 
pearance, as  a  rule,  in  the  following  order:  The  child  will 
complain  of  a  sense  of  stiffness  on  rising  from  bed  in  the 
morning,  and  will  show  a  tenderness,  however  slight,  in  the 
vicinity  of  one  or  the  other  hip  by  an  awkwardness  of  gait, 
a  disposition  to  fall  on  the  most  trivial  provocation.  This 
condition  may  last  several  days  or  several  weeks;  but  mean- 
while, or  perhaps  following  it,  there  will  come  a  sense  of 
fatigue  after  play  or  a  short  walk.  Occasionally,  when  thus 


CHRONIC  ARTICULAR  OSTITIS  :  DIAGNOSIS. 

complaining,  the  child  will  refer  pain  to  the  region  of  the  hip, 
and  a  little  later  the  pain  will  be  referred  to  the  knee,  usually 
just  above  the  patella.  This  site  is  not  constant,  for  the 
sides  of  the  knee  and  the  popliteal  space  come  in  for  their 
share  quite  frequently. 

When  these  shifting  pains  attract  notice  an  exacerbation 
is  approaching,  and  the  symptoms  will  soon  become  more 
acute.  At  the  same  time  there  will  be  restlessness  during 
sleeping  hours,  and  screaming  while  asleep.  This  latter 
partakes  more  of  a  shriek — one  or  too — and  then  an  interval, 
followed  by  others.  It  is  known  as  the  ostitic  cry,  being  re- 
garded by  some  as  peculiar  to  bone  lesions  in  the  vicinity 
of  joints.  In  seeking  for  a  history  of  this  cry,  however, 
one  must  not  expect  to  hear  that  the  child  invariably  cries 
aloud  without  waking.  It  very  often  happens  that  two  or 
three  long  cries  in  sleep  will  be  followed  by  a  waking  and 
continuous  crying.  Then  the  little  one  will  go  to  sleep 
again,  and  the  same  procedures  will  recur. 

The  loss  of  sleep  and  the  harassing  pain  by  day  will 
naturally,  in  many  children,  induce  a  loss  of  appetite  an 
impaired  digestion  and  an  irritability  of  temper.  These 
complete  the  symptoms  in  the  first  stage. 

The  signs  furnish,  after  all,  the  important  points  in  diag- 
nosis, and  for  convenience  and  system  I  shall  arrange  them 
in  the  order  of  observation. 

INSPECTION. — The  lameness  is  the  first  sign  that  attracts 
one's  attention,  and  this  comes  as  near  to  being  diagnostic 
as  any  other  sign  that  presents.  As  described  in  the 
chapter  on  clinical  history  the  limp  is  peculiarly  a  "  hip- 
limp."  Every  effort  the  child  makes  in  walking  is  directed 
toward  the  saving  of  the  limb.  The  periarticular  muscles 
seem  to  lock  the  joint,  and  the  motion  takes  place  chiefly 
at  the  knee  and  in  the  lumbar  spine.  The  step  is  short, 
yet  firmly  taken,  and  differs  materially  from  the  limp  of  a 
paretic  limb.  During  the  first  few  days  there  may  be  an 
exception  to  this,  as  the  foot  appears  to  be  unsteadily  placed 
upon  the  floor,  and  as  the  weight  is  thrown  upon  it  there  is 
a  slight  swaggering  from  side  to  side.  This,  however,  is 
an  exceptional  limp,  and  serves  to  bring  out  the  rule  in 
stronger  relief. 

Both  in  standing  and  in  walking  the  limb  will  vary  a  little 
between  the  horizontal  line  and  outward  rotation.  In 
standing,  furthermore,  the  limb  is  advanced  a  little  in  order 
that  the  bulk  of  the  weight  may  be  thrown  upon  the 


272  DISEASES  OF  THE   HIP. 

sound  limb,  and  the  foot  is  either  on  a  parallel  plane  with 
its  fellow,  or  is  a  little  everted.  In  my  own  experience  I 
have  seldom  found  the  inversion  described  as  belonging  to 
the  first  stage.  The  most  common  position  is  a  position 
without  inversion  or  eversion.  If,  however,  the  examination 
be  made  in  the  midst  of  an  exacerbation  the  limb  will  be 
well  advanced,  and  the  foot  in-  or  everted  in  accordance 
with  the  muscles  or  tissues  about  the  joint  implicated. 

The  change  in  the  nates  next  attracts  one's  attention,  and 
here  is  found  a  loss  of  the  normal  depressions — the  expres- 
sion, so  to  speak,  is  gone.  It  is  like  looking  at  a  face  in 
which  one  side  is  partially  paralyzed,  and  the  difference 
can  only  be  appreciated  by  comparison.  The  ilio-femoral 
creases  are  shorter,  and  are  on  a  lower  plane:  frequently 
one  only  will  remain.  True,  this  appearance  is  present  in 
certain  forms  of  paralysis  or  in  periarthritic  lesions,  yet  the 
signs  are  valuable  in  connection  with  symptoms  and  a 
history.  In  some  cases  the  creases  will  be  like  those  on 
the  sound  side,  but  the  parts  about  the  crest  will  be  more 
prominent,  and  the  whole  of  one  side  of  the  nates  will  seem 
to  be  raised,  the  limbs  being  parallel.  The  size  of  the  thigh 
is  less  than  that  of  its  fellow,  and  this  difference  will  be 
early  appreciated  by  comparison.  It  is  a  clinical  fact — 
sufficiently  elaborated  in  the  precedingchapter,  that  atrophy 
begins  early  in  an  ostitis  affecting  the  centres  of  develop- 
ment, and  with  a  knowledge  of  this  fact  the  observer  will 
look  for  the  signs  of  the  same. 

PALPATION. —  The  tactus  eruditus  does  not  help  one  much 
in  the  diagnosis  of  this  disease.  It  is  of  more  value  in  a 
negative  than  in  a  positive  way.  If  the  pathological  pro- 
cess have  advanced  to  such  a  degree  that  periosteal  thick- 
ening has  been  induced,  then  this  can  be  recognized  by  pal- 
pation; but  it  must  be  borne  in  mind  always  that  every 
step  of  the  examination  should  be  conducted  by  com- 
parison. With  flabby  muscles  the  size  of  the  trochanter 
will  look  and  feel  larger  than  normal,  provided  the  other 
is  not  grasped  at  the  same  time.  Pressure  over  the  bony 
prominence  with  this  periosteal  thickening  will  elicit  bone, 
tenderness,  which  is  a  sign  of  questionable  value.  The  in- 
guinal glands  may  be  enlarged,  yet  it  frequently  happens 
that  the  glands  are  not  enlarged  even  when  the  disease  is 
far  advanced;  so  that  very  little  reliance  can  be  placed  on 
the  conditions  these  structures  present. 

FUNCTIONS  OF  THE  JOINT. — By  far  the  more  important  aid 


CHRONIC  ARTICULAR  OSTITIS :  DIAGNOSIS.       273 

to  diagnosis  is  obtained  from  a  test  of  the  joint  functions,  in- 
cluding not  only  the  condition  of  the  articular  surfaces  (so 
far  as  external  examination  can  determine),  but  the  condi- 
tion of  the  surrounding  muscles,  the  extensors  and  the  ad- 
ductors especially.  If  one  have  any  fears  about  employing 
passive  motion,  the  child  can,  while  balancing  on  the  sound 
limb,  be  induced  to  attempt  active  motion.  On  many  oc- 
casions when  I  have  been  debarred  the  privilege  of  moving 
the  thigh  myself,  I  have  gained  much  positive  knowledge  by 
inducing  the  patient  to  execute  various  movements  with  the 
limb.  With  the  present  views  I  hold  concerning  the  lesions 
in  and  near  the  hip-joint,  I  entertain  no  fear  whatever  of 
doing  the  least  amount  of  harm  to  the  parts  by  passive 
movements,  no  matter  what  the  lesion  may  be,  provided 
they  be  made  without  an  anaesthetic.  I  have  never  found 
it  necessary  to  employ  an  anaesthetic  in  conducting  an  ex- 
amination except  on  one  or  two  occasions.  These  excep- 
tions were  in  a  patient  with  a  few  female  relatives  in  the 
room,  and  I  could  not  execute  a  single  movement  without 
the  premonition  of  a  sympathetic  shriek.  The  very  signs 
on  which  one  is  to  rely  in  diagnosticating  an  early  ostitis 
are  obscured  by  the  anaesthetic. 

There  is  no  necessity  for  being  rough  or  in  any  way  violent 
in  the  manipulations.  Secure,  if  possible,  a  table  for  this  part 
of  the  examination,  and  let  it  be  covered  with  a  blanket  or 
other  soft  material.  Never  test  the  joint  function  with  the 
patient  lying  on  the  bed  if  it  can  be  helped.  Let  the  patient 
be  divested  of  all  clothing  below  the  waist.  It  is  better  still 
to  remove  every  thing,  save  perhaps,  the  shirt  worn  next 
the  skin.  Now  let  the  dorsal  decubitus  be  taken  on  the 
table  thus  prepared,  and  get  the  child's  confidence  by  manip- 
ulating the  sound  limb.  Put  the  thigh  through  all  the 
normal  movements:  flexion,  extension,  abduction,  adduc- 
tion, inward  rotation  and  outward  rotation — all  to  their  ex- 
treme limits.  This  will  refresh  our  knowledge  as  to  the 
normal  movements  both  in  kind  and  degree,  and  at  the 
same  time  the  patient  will  be  prepared  for  an  examination 
of  the  limb  of  the  side  diseased. 

As  soon  as  the  thigh  is  grasped  with  the  hand  of  the  ex- 
aminer the  least  resistance  will  be  appreciated,  and  one  can 
often  tell  in  an  instant  what  movements  will  be  limited. 
Carry,  without  the  employment  of  force,  the  thigh  over  the 
full  extent  to  which  flexion  can  be  made,  noting  the  while 
any  reflex  resistance  that  may  present.  It  will  be  found 


274  DISEASES  OF  THE  HIP. 

that  the  resistance  point  will  be  between  ninety  and  forty- 
five  degrees.  The  other  thigh  can  be  easily  flexed  to  its 
limit  by  way  of  comparison.  For  purposes  of  record  the 
goniometer,  as  represented  in  Fig.  28,  is  a  very  useful 
instrument.  The  one  I  have  represented  is  taken  from  Dr. 
Knight's  "Orthopcedia,"  though  modified  in  the  marking. 
The  fixed  arm  when  in  use  rests  with  the  graduated  arc 
against  the  side  of  the  body,  the  joint  over  the  joint  whose 
deformity  is  to  be  measured,  while  the  movable  arm  rests 
against  the  limb  parallel  with  its  longitudinal  axis.  The 
angles  can  then  be  read  off  on  the  graduated  arc.  A 
little  practice  with  the  goniometer  will  enable  one  to  esti- 
mate quite  closely  any  given  deformity,  even  without  em- 
ploying the  instrument. 
All  orthopedists  insist  more  or  less  on  the  position  of 


FIG.  28.— A  GONIOMETER. 

the  body  and  the  relationship  of  the  spinal  column  to  the 
table  or  bed  on  which  the  examination  is  conducted.  All 
the  spinous  processes  should  be  in  contact  with  the  under- 
lying surface,  and  in  moving  the  limb  this  relationship 
should  be  maintained.  I  have  been  much  pleased  with  the 
method  Mr.  Thomas,  of  Liverpool,  adopts  for  securing  this 
fixation  of  the  body.  The  accompanying  figure  (No.  29)  well 
represents  the  method.  The  arm  of  the  sound  side  thus 
placed  in  the  popliteal  space  retains  the  corresponding 
thigh  acutely  flexed  on  the  abdomen,  thus  preventing 
tilting  of  the  pelvis  during  movements  of  the  diseased 
member. 

Given  now  the  arc  of  motion  in  the  different  directions, 
significance  shall  we  attach  to  the  various  degrees  of 


CHRONIC  ARTICULAR   OSTITIS :   DIAGNOSIS.       275 

resistance  encountered  ?  If  flexion  be  resisted,  however 
little,  even  though  all  the  other  movements  be  perfect,  we 
have  one  of  the  early  signs  of  a  chronic  ostitis.  If  to  this 
be  added  a  limited  arc  of  abduction  and  of  rotation,  the 
signs  are  thus  rendered  more  significant.  As  a  rule  these 
three  signs,  viz.,  resistance  to  flexion  beyond  sixty  degrees, 


FIG.  20.— MR.  THOMAS'  METHOD  OF  SECURING  FIXATION  OF  THB  BODY  WHILE  TESTING 
THE  JOINT  FUNCTIONS. 

to  abduction,  and  to  rotation,  are  among  the  earliest,  if  not 
the  earliest,  one  finds  in  a  thorough  examination.  Indeed, 
with  these  three  present  a  diagnosis  can  be  made.  It  is 
very  seldom  that  one  of  these  signs  is -present  without 
the  others.  Exceptionally,  the  flexion  sign  is  the  only  one 
that  a  careful  test  will  discover,  but  when  the  adductors 


276  DISEASES   OF  THE   HIP. 

are  in  reflex  contraction  there  is  a  limit  to  full  flexion. 
Exceptionally,  too,  an  articular  ostitis  may  be  present  and 
the  joint  functions  in  every  way  perfect,  but  the  exceptions 
are  so  rare  that  the  average  practitioner  will  never,  in  my 
opinion,  have  occasion  to  think  of  such  a  contigency  during 
a  natural  life-time.  Very  many  cases  on  their  first  examin- 
ation give  a  hip  in  which  all  the  surrounding  muscles  are 
in  a  state  of  reflex  spasm — no  movement  whatever  is 
allowed. 

SENSITIVENESS  OF  BONE  AND  JOINT. — To  determine  the 
tenderness  of  the  joint  the  most  common  method  is  to 
sharply  strike  the  heel  or  the  knee  in  the  direction  of  the 
long  axis  of  the  limb.  This  has  to  me  been  a  very  unsatisfac- 
tory test.  In  the  first  place,  the  periarticular  muscles  are 
in  such  a  state  of  reflex  spasm  that  the  joint  is  practically 
immobilized,  and  thus  protected  from  concussion.  In  the 
second  place  one  has  to  strike  with  such  force  to  get 
any  response,  that  not  only  is  there  danger  of  fatal  injury 
to  the  joint  by  breaking  down  the  articular  cartilage  in  some 
weak  point,  but  the  impression  conveyed  to  the  patient  and 
friends  present  is  one  of  extreme  roughness  in  examina- 
tion. At  all  times  and  under  all  circumstances  rough 
methods  should  be  avoided.  A  plan  that  I  have  adopted 
is  free,  I  think,  from  this  objection,  and  certainly  I  can  get 
much  more  information  about  the  condition  of  the  joint 
than  I  can  by  the  concussion  method.  I  make  a  lever  of 
the  patient's  thigh,  having  for  the  weight  or  resistance  the 
acetabulum,  for  the  fulcrum  the  palm  of  my  hand,  and  for 
the  power  the  other  hand.  Bony  tenderness  if  present  will 
generally  be  found  over  the  trochanter  or  shaft.  As  a 
rule,  however,  one  will  rarely  find  any  joint-tenderness  in 
the  early  stage  of  this  disease,  unless  perhaps  the  examina- 
tion be  made  in  the  midst  of  an  exacerbation.  The  greatest 
tenderness  will  be  in  the  fibrous  structures  enclosing  the 
joint,  and  these  can  be  the  more  easily  reached  just  over 
the  digital  fossa  and  in  the  groin. 

While  the  above  examination  is  conducted,  imformation 
will  be  gathered  concerning  the  mode  of  invasion  and  the 
behavior  of  the  patient  by  day  and  by  night.  The  family 
history  must  be  obtained,  and  it  must  be  remembered  that 
due  tact  is  to  be  employed  in  eliciting  facts  in  this  connec- 
tion. The  personal  history  must  not  be  forgotten,  for  on 
this  the  existence  frequently  of  a  strumous  diathesis  de- 
pends. 


CHRONIC  ARTICULAR   OSTITIS  :   DIAGNOSIS.       277 

Studying  the  behavior  of  the  patient  at  home  it  will  be 
learned  that  every  care  has  been  made  to  protect  the  joint. 
The  first  thing  the  mother  will  have  noticed  is  the  difficulty 
the  child  experiences  in  getting  on  the  shoe  and  stocking. 
There  is  no  severer  test  to  the  functions  of  the  hip,  and  all 
through  the  course  of  the  disease  this  serves  as  a  petty 
annoyance.  Mention  has  already  been  made  of  the  peculi- 
arity of  gait,  the  restlessness  at  night,  the  peevishness,  the 
loss  of  appetite,  etc. 

I  have  endeavoured  to  give  the  history,  the  symptoms, 
and  the  signs  by  which  a  diagnosis  can  be  easily  made  in 
a  typical  case  of  chronic  articular  ostitis  of  the  hip.  The 
first  exacerbation  is  usually  delayed  some  weeks  or  months, 
but  occasionally  it  appears  very  early,  and  the  diagnosis  is 
thus  rendered  very  difficult.  In  young  children,  however, 
I  do  not  believe  in  very  early  exacerbations. 

Three  years  ago  a  little  girl  of  five  years  was  brought  to 
me  complaining  of  pain  in  thigh  and  knee,  left  side.  She 
had  been  ailing  only  three  days,  and  there  was  no  signs 
such  as  lameness  or  stiffness  or  awkwardness  in  gait  even 
prior  to  that  time.  I  could  get  no  history  of  a  fall  or 
injury  otherwise  sustained,  and  the  mother  insisted  that 
the  family  history  on  both  sides  was  good.  I  found  that 
the  little  patient  kept  her  thigh  flexed,  yet  on  attempts  at 
passive  motion  I  met  with  no  resistance  whatever  in  making 
flexion  and  extension  to  extreme  limits.  Rotation,  ab-  and 
adduction  were  limited  to  a  readily  perceptible  degree.  On 
the  strength  of  these  three  signs  I  recorded  an  interrogated 
diagnosis  of  chronic  articular  ostitis,  and  reserved  a 
positive  diagnosis  for  a  future  visit.  A  week  later  she  was 
"free  from  lameness,  the  thighs  equal  in  size  and  limbs 
equal  in  length,  movements  perfect,  and  child  rests  well 
nights."  A  fortnight  afterwards  I  recorded  "no  resistance 
at  all  in  movements,  child  cured  and  no  disease  at  the  hip." 

In  this  case  I  should  not  have  placed  any  confidence  in 
the  symptoms  developing  coincidently  with  the  signs.  In 
another  case  I  saw  a  few  days  before  this  one  came  under  my 
observation  there  was  a  history  of  symptoms  coming  on 
one  week  after  the  first  sign.  The  patient  was  a  female, 
aged  eleven  months  only,  and  the  mother  gave  a  history 
of  a  fall  six  weeks  prior  to  the  date  of  my  first  examina- 
tion. The  child  fell  on  the  hip,  and  cried  a  little  at  the 
time,  but  soon  became  quiet  and  did  not  complain  any  for 
a  week.  Then  quite  suddenly  the  limb  became  quite 


2/8  DISEASES  OF  THE  HIP. 

tender,  and  the  child  would  cry  bitterly  if  the  joint  were 
disturbed.  A  week  afterward  exstension  was  applied,  but 
this  seemed  to  add  to  the  discomfort.  I  could  find  neither 
shortening  nor  atrophy.  The  adductor  muscles  were  in 
slight  reflex  spasm.  There  was  resistance  and  pain  to 
flexion  beyond  ninety  degrees  in  the  extremes  of  exten- 
sion, of  rotation,  and  of  adduction  an  appreciable  resist- 
ance was  encountered.  At  the  end  of  a  week  the  signs 
were  less  marked,  yet  I  felt  satisfied  that  I  had  here 
to  deal  with  a  case  of  bone  disease.  An  exacerbation  a 
month  later  ushered  in  the  second  stage,  and  the  diagnosis 
was  settled  beyond  question. 

In   differentiating  this    disease  in   its  early   stage   the 
following  affections  present  for  consideration: 
I.  Contusions  and  Sprains. 
II.  Muscular  Rheumatism. 

III.  Neuroses  of  the  Hip. 

IV.  Infantile  Spinal  Paralysis  (Poliomyelitis). 
V.  Periarthritis. 

VI.   Bursitis. 
VII.  Acute  Synovitis. 
VIII.  Periostitis  of  the  Hip. 

IX.  Ostitis  of  the  Ilium,  including  Sacro-iliac  Disease. 
X.  Vertebral  Ostitis. 

I.  CONTUSIONS  AND  SPRAINS. 

The  clinical  features  of  these  simple  lesions  have  been 
discussed  in  Chapter  III.  The  diagnosis  is  quite  readily 
made  when  violence  has  been  done  to  the  external  parts 
and  when  the  date  of  tne  injury  is  well  known.  It  be- 
comes more  obscure,  however,  when  nothing  can  be  seen 
externally  and  when  the  accident  is  questionable.  We 
must  then  make  a  diagnosis  chiefly  by  exclusion. 

Take,  for  instance,  the  following  case  I  saw  last  spring:  A 
well-developed  boy,  aged  five  years,  had  a  peculiar  gait. 
It  could  scarcely  be  described  as  a  limp,  yet  he  favored  the 
right  hip  and  had  been  walking  this  way  for  eight  days.  The 
day  before  this  sign  was  observed  he  fell  while  at  play,  the 
limbs  being  thrown  into  complete  abduction.  The  mother 
saw  him  fall  but  he  got  up  immediately  and  ran  off  to  play 
without  showing  any  evidences  of  sprain.  He  passed  a  good 
night,  and  next  day  toward  the  evening  it  was  noticed  that 
he  favored  the  right  limb  a  little.  From  that  time  he  rested 


CHRONIC  ARTICULAR  OSTITIS  :  DIAGNOSIS.       279 

well  at  night,  but  was  more  stiff  in  the  morning  than  in  the 
latter  part  of  the  day.  At  no  time  did  he  complain  of  pain 
in  any  part  of  the  limb.  Here,  now,  was  the  morning  stiff- 
ness, the  lameness  without  symptoms,  and  eight  days  had 
passed  without  improvement.  I  was  prepared  to  find  some 
resistance  on  manipulating  the  thigh,  although  I  could 
detect  no  loss  in  contour  of  the  nates.  I  did  not  find  any 
impairment  of  the  joint  functions  on  pretty  thorough  ex- 
amination, and  recorded  as  diagnosis  a  sprain,  enjoining 
rest  for  a  few  days.  Within  a  month  all  this  peculiarity 
of  gait  disappeared  and  the  boy  was  perfectly  well. 

It  was  not  so  in  the  case  of  a  girl  aged  two  years  whom 
I  saw  last  fall.  There  was  a  history  of  a  sprain  while  at 
play  two  weeks  before  she  came  under  observation.  A 
playfellow  had  pulled  the  right  leg,  causing  a  little  pain 
apparently  at  the  time.  She  rested  well  the  same  night 
but  next  morning  was  stiff  and  walked  lame.  The  limb, 
as  she  stood  and  walked,  was  markedly  abducted.  The 
lameness  persisted  and  the  limb  had  become  quite  tender, 
so  that  she  cried  if  any  one  moved  it.  With  a  little  care, 
however,  the  thigh  could  be  moved  over  normal  arcs,  the 
resistance  readily  giving  way.  She  had  begun  to  cry  aloud 
during  sleep  and  to  manifest  an  amount  of  tenderness  that 
led  me  to  regard  this  as  an  early  exacerbation  in  bone 
disease.  A  week  later  she  was  walking  more  easily,  but  I 
found  for  the  first  time  marked  resistance  to  rotation  and 
abduction.  The  subsequent  notes  of  the  case  show  a 
gradual  progress  to  the  second  stage,  with  abscess,  etc. 

A  girl  aged  five  came  under  my  observation  in  the  early 
part  of  August  with  a  lameness  of  nine  days'  standing.  I 
found  a  slight  resistance  to  outward  rotation  while  all  the 
other  movements  were  free  and  painless.  The  child  had 
fallen  over  the  railing  of  a  stoop  on  the  day  before  the 
lameness  came  on  and  had  bruised  both  the  shoulder  and 
the  hip.  Ecchymosis  over  trochanter  remained  up  to  the 
date  of  my  examination;  there  were  no  acute  symptoms 
and  there  was  no  sign  save  the  ecchymosis,  the  lameness 
and  the  resistance  to  outward  rotation;  hence  I  made  out 
a  contusion  of  the  hip  and  enjoined  rest  for  a  week,  when 
J  found  the  resistance  to  rotation  gone,  but  the  child  was 
lamer.  Then  I  waited  a  week  longer  and  the  mother  re- 
ported that  the  lameness  was  not  so  marked,  yet  the  child 
had  more  difficulty  in  going  up  and  down  stairs.  All  these 
signs  passed  away  in  the  course  of  two  months  without  any 


280  DISEASES  OF  THE  HIP. 

exacerbation,  and  six  months  afterward  I  examined  the 
case  again  quite  carefully,  to  find  nothing  in  the  way  of  sign 
or  symptom. 

The  points  in  differential  diagnosis  are: 

1.  Sprains  and  contusions  are  always  the  direct  result  of 
trauma. 

Chronic  articular  ostitis  is  seldom  the  direct  result  of 
trauma. 

2.  Sprains  and  contusions  give  signs  within  twenty-four 
hours  of  the  accident.     Symptoms  usually  follow  imme- 
diately. 

Chronic  articular  ostitis  may  not  show  any  signs  until 
two  or  three  weeks  after  the  accident  supposed  to  have 
stood  in  causative  relationship.  The  symptoms  will  not 
appear  until  after  the  establishment  of  the  signs. 

3.  In  the  one  there  is,  as  a  rule,  no  resistance  to  the  joint 
movements.      In   the  other,  reflex  muscular  contractions, 
causing  resistance  to  passive  motion,  as  a  rule,  are  present 
within  the  first  fortnight  after  the  initial  lameness. 

4.  In  the  one  the  signs  are  so  pronounced  that  medical 
advice  is  sought  within  the  first  week.     In  the  other  the 
signs  are  so  obscure  that  medical  advice  is  rarely  sought 
within  a  month. 

5.  Sprains  and  contusions  are  more  common  in  adult  life, 
chronic  articular  ostitis  in  early  life. 

6.  In  doubtful  cases  time  will  effect  a  cure  in  the  former 
and  will  have  no  influence  on  the  latter. 


II.  MUSCULAR  RHEUMATISM  OF  THE  HIP. 

Muscular  rheumatism,  or,  myalgia,  from  cold  or  expo- 
sure, gives  certain  symptoms  that  are  very  like  those  one 
finds  in  the  early  exacerbation  of  a  chronic  bone  disease, 
and  the  lameness,  too,  of  the  former,  is  sometimes  difficult 
to  dissociate  from  that  of  the  latter.  The  "growing  pains" 
that  children  complain  of  are  generally  rheumatic,  and 
their  relationship  to  certain  signs  of  articular  ostitis  are 
not  treated  with  sufficient  consideration,  so  that  in  the  ma- 
jority of  cases  these  "  growing  pains"  are  but  the  symptoms 
of  the  more  formidable  disease  we  are  now  discussing. 

A  case  in  a  boy  aged  twelve  years,  whom  I  saw  in  May, 
1879,  and  one  in  a  boy  of  the  same  age,  seen  first  in  June, 
1879,  will  illustrate  the  difficulty  in  differentiating  the  two 


CHRONIC  ARTICULAR  OSTITIS  :  DIAGNOSIS.       28 1 

affections.  The  first  was  reported  to  have  been  troubled 
much  with  "rheumatic"  pains  for  two  years,  but  the  family 
history  was  free  from  rheumatism.  When  he  first  presented 
for  examination  it  was  for  a  lameness  that  had  lasted  only 
five  days.  He  had  been  at  school,  and  had  been  perfect  in 
limb,  so  far  as  I  could  learn,  when  one  day,  without  known 
exciting  cause,  he  was  seized  with  severe  pain  in  the  an- 
terior and  inner  surface  of  the  right  thigh.  It  gradually 
diminished  in  severity  during  the  day,  and  during  the  fol- 
lowing night  he  had  no  pain,  but  next  day  he  was  quite 
lame.  On  walking  the  pain  was  excited  again,  and  it  was 
further  called  into  action  by  sitting  a  long  while.  The 
same  region  was  always  affected  and  yet  he  was  not  troubled 
any  during  the  night.  The  natis  presented  a  moderate 
flattening  and  the  crease  was  obliterated.  Resistance  was 
offered  when  the  limb  was  completely  extended.  A  coun- 
ter-irritant was  employed  and  within  less  than  a  month  all 
symptoms  had  disappeared,  all  signs  had  disappeared.  I 
saw  him  several  times  during  the  following  year  and  always 
with  negative  results  on  examination. 

The  other  boy  was  also  twelve  years  of  age  and  had  been 
lame  a  few  weeks  three  years  before.  He  made  a  perfect 
recovery,  it  seemed  from  the  history,  and  then,  during  the 
early  months  of  1879,  two  and  a  half  years  later,  the  lame- 
ness, accompanied  by  pain,  returned,  affecting  the  same 
limb.  The  pain  was  so  great  that  he  did  not  leave  his  bed 
for  two  months.  Since  he  left  his  bed  the  pain  had  been 
very  insignificant,  unless  after  much  exercise.  It  seldom 
caused  any  loss  of  sleep.  When  I  examined,  three  months 
after  his  confinement  to  bed,  I  could  detect  no  change  in  the 
nates  except  an  exaggeration  of  the  dimple  above  trochanter 
of  the  side  affected.  The  limbs  were  parallel  and  he  could 
stand  on  either  limb  with  equal  facility.  There  was,  how- 
ever, a  half-inch  atrophy  of  the  thigh  and  of  the  calf,  and 
a  little  resistance  offered  as  the  extreme  limits  of  abduction 
and  outward  rotation  were  made.  The  joint  was  free  of 
tenderness  and  the  thigh  could  be  flexed  and  extended  to 
extreme  limits  without  the  least  resistance.  This  case  re- 
mained in  hospital  under  daily  observation  for  three  weeks 
••and  at  the  end  of  that  time  there  could  not  be  detected  any 
lameness,  while  the  movements  were  perfect  in  kind  and 
degree.  Notwithstanding  this  change,  I  had  some  mis- 
givings about  discharging  the  boy,  and  he  was  allowed 
home  for  a  few  days.  He  failed  to  return,  and  six  months 


282  DISEASES  OP  THE  HIP. 

afterward  I  learned  that  he  was  on  crutches,  and  was  in 
another  exacerbation  of  joint-and-bone  disease. 

Now,  wherein  did  these  two  cases  differ?  Let  me  state 
that  the  first  was  diagnosticated  bone  disease  and  the  latter 
rheumatism.  The  first  proved  to  have  been  rheumatism 
and  the  second  proved  to  be  bone  disease.  With  the 
history  of  each  before  me,  and  with  my  mind  divested  of  all 
bias  I  can  readily  note  the  points  of  difference.  In  the  first 
there  was  a  brief  lameness,  in  the  second  there  was  a  six 
months'  lameness  at  least;  in  the  first  there  was  a  rheumatic 
history,  in  the  second  there  was  none;  in  the  first  the  acute 
period  lasted  twelve  hours,  in  the  second  nearly  two  months; 
in  the  first  there  was  no  clear  history  of  any  preceding  lame- 
ness, in  the  second  there  was  such  history;  in  the  first  there 
was  no  pain  at  night,  in  the  second  there  was  occasional 
pain  at  night;  in  the  first  there  were  no  signs  save  resist- 
ance to  extension,  in  the  second  the  limb  could  not  be  ro- 
tated well,  or  abducted  or  adducted;  in  the  one  there  was 
no  atrophy,  in  the  other  there  was  atrophy.  Jnstead  of  in- 
terpreting that  confinement  to  bed  two  months  as  due  to 
rheumatism,  I  should  have  interpreted  it  as  the  second  ex- 
acerbation of  chronic  articular  ostitis. 

The  first  case  was  not  so  clear  as  that  of  a  little  girl  three 
and  a  half  years  of  age,  who  was  brought  to  me  in  the  win- 
ter of  1878  complaining  of  pain  about  the  crest  of  the  left 
ilium  and  in  the  gluteal  region  of  same  side.  She  had  been 
complaining  of  pain  and  had  been  resting  poorly  at  night  for 
three  weeks.  There  was  no  lameness,  and  a  careful  test  of 
the  functions  of  both  hip  and  spine  was  attended  with  ab- 
solutely negative  results.  I  had  under  treatment  at  the 
time  a  sister,  a  few  years  her  senior,  for  chronic  rheumatism 
affecting  the  knee,  and  I  knew  her  father  to  be  the  subject 
of  crippling  rheumatism.  I  had,  therefore,  no  difficulty  in 
diagnosticating  rheumatic  neuralgia  in  this  case,  and  put 
her  on  treatment  for  the  same.  She  made  a  perfect  re- 
covery in  less  than  a  fortnight,  and  I  learned  four  and  a  half 
years  later  that  she  had  never  had  any  relapse. 

It  is  unnecessary  to  cite  cases  in  adults,  because  these  as 
a  rule  offer  no  difficulties  in  diagnosis,  especially  in  the 
early  stages.  The  articular  varieties  are  usually  associated 
with  similar  lesions  in  other  joints,  and  hence  do  not  offer 
any  obstacles  until  deformity  has  arisen.  When  I  come  to 
speak  of  the  diagnosis  of  the  second  and  the  third  stages 
these  lesions  will  come  up  for  differentiation. 


CHRONIC  ARTICULAR   OSTITIS  :  DIAGNOSIS.       283 

To  sum  up,  then,  the  points  in  differential  diagnosis  be- 
tween the  first  stage  of  a  chronic  articular  ostitis  of  the  hip 
and  a  rheumatism  of  the  hip, 

1.  In  the  one  the  lameness  precedes  the  pain,  in  the  other 
the  pain  conies  first,  and  frequently  lameness  is  not  present. 

2.  In  the  one  there  is  no  hyperaesthesia,   in   the  other 
muscular  hyperaesthesia  is  a  prominent  feature. 

3.  In  the  one  there  is  as  a  rule  no  resistance  to  joint 
movements  and  no  reflex  muscular  spasms  in  the  adduc- 
tors or  flexors;  in  the  other  this  resistance  occurs  early  and 
the  spasm  is  easily  excited. 

4.  In  the  one  there  is  a  rheumatic  family  history,  in  the 
other  there  is  often  a  tuberculous  history. 


III.  NEUROSES  OF  THE  HIP. 

The  prevalence  of  nervous  diseases  in  large  cities  brings 
us  more  and  more  in  contact  with  the  true  and  false 
arthropathies  of  neurotic  origin.  I  was  formerly  under 
the  impression  that  these  phenomena  were  limited  to  the 
period  of  adolescence,  but  latterly  I  have  seen  them  in 
young  children,  and  hence  find  it  important  to  differen- 
tiate the  more  closely  between  these  neuroses  of  the  hip 
and  chronic  bone  disease.  It  is  necessary  to  fully  ap- 
preciate this  fact,  viz.,  that  because  a  child  comes  of  a  neu- 
rotic family  and  even  has  a  decidedly  neurotic  tempera- 
ment itself,  it  does  not  follow  that  a  true  bone  disease 
about  the  epiphyses  is  at  all  improbable.  In  other  words, 
the  neurotic  diathesis  does  not  protect  against  the  develop- 
ment of  strumous  diseases.  The  two  diatheses  sometimes 
run  hand  in  hand.  Some  of  the  most  destructive  cases  of 
bone  and  joint  disease  I  have  ever  seen  have  occurred  in  pa- 
tients who  were  typically  neurotic.  It  must  be  constantly 
borne  in  mind  that  chronic  articular  ostitis  has  its  own  pe- 
culiar clinical  expression,  and  however  masked  this  may  be 
by  nervous  phenomena  this  expression  should  always  be 
recognized.  Neuroses,  like  bone  diseases,  have  their  exacer- 
bations, and  but  for  the  thoroughness  of  the  remissions,  the 
differential  diagnosis  would  become  extremely  harassing. 
Take,  for  instance,  a  case  I  have  reported  on  page  62.  This 
boy  had  an  exacerbation  in  1876.  Three  years  afterward 
he  had  another,  and  again  after  the  lapse  of  four  years  he 
was  similarly  affected.  Prompt  recoveries  were  effected  on 


284  DISEASES   OF  THE  HIP. 

every  occasion,  and  a  limp  was  not  left  over.  Exception- 
ally, though,  the  lameness  does  persist,  and  its  explanation 
is  possibly  in  a  lesion  of  the  anterior  columns  of  the 
cord. 

I  saw,  for  the  first  time,  a  girl  eight  years  of  age,  in 
the  summer  of  1880.  The  family  history  was  decidedly 
tuberculous,  and  the  patient  was  a  feeble,  poorly  nourished 
child.  While  she  walked  with  ease  there  was  a  marked 
limp  in  her  gait,  and  the  left  hip  was  favored.  I  could  not 
elicit  any  joint-tenderness,  and  could  not  detect  any  atrophy. 
Considerable  muscular  resistance  was  offered  to  passive 
flexion  of  90°  even,  and  beyond  this  angle  the  thigh  could 
not  be  moved.  The  other  movements  were  made  with  ease. 
I  found  the  dorso-lumbar  spine  and  the  limb  itself  very  hy- 
peraesthetic.  Four  weeks  before  she  came  under  my  obser- 
vation she  fell  on  the  side-walk,  but  did  not  seem  to  sustain 
any  injury.  It  was  two  weeks  before  she  began  to  walk 
lame  and  to  complain  of  any  pain.  Her  sleep  had  not  been 
disturbed.  Under  a  placebo  the  lameness  and  the  pain  dis- 
appeared in  a  month,  and  I  examined  her  a  month  after- 
ward with  negative  result.  In  tracing  out  the  case  three 
years  afterward,  I  found  that  the  lameness  had  soon  re- 
turned, and  while  I  could  not  discover  any  symptoms  of 
disease  I  found  this  favoring  of  the  limb  still  present. 

In  some  cases,  indeed  in  nearly  all  cases  of  contraction  the 
result  of  nerve-irritation  a  little  force  is  all  that  is  necessary 
to  overcome  this  completely.  Last  spring  a  girl  twelve 
years  of  age  came  limping  into  my  office,  and  I  learned  that 
all  her  symptoms  and  signs  came  on  quite  suddenly  four 
days  proceeding  this  visit.  The  mother  knew  of  no  cause, 
and  I  could  not  find  any.  The  right  thigh  was  locked,  as 
it  were,  on  the  pelvis,  at  an  angle  of  135°,  and  there  was  an 
apparent  shortening  of  one  and  a  quarter  inches.  The  girl 
seemed  generally  hyperaesthetic,  and  I  at  once  made  up  my 
mind  that  this  was  a  case  of  hysterical  contraction — a  neu- 
rosis of  the  hip.  With  a  little  coaxing  I  succeeded  in  mov- 
ing the  thigh  over  a  small  arc,  and  then,  finding  the  con- 
traction give  way,  I  rapidly  and  with  considerable  force 
moved  it  in  all  directions  over  the  full  extent,  immediately 
after  which  I  made  her  walk  across  the  floor.  This  she  did 
with  scarcely  a  trace  of  lameness. 

The  signs  of  bone  disease  have  been  sufficiently  elabor- 
ated to  make  the  introduction  of  further  cases  in  this  con- 
nection unnecessary,  and  I  shall  content  myself  with  an 


CHRONIC  ARTICULAR  OSTITIS :   DIAGNOSIS.       2§5 

enumeration  of   some  of  the  more   prominent  points  in 
differentiation. 

1.  In  a  neurosis  of   the  hip  a  neurotic  element  in  the 
family  history  will,  as  a  rule, be  easily  obtained;  in  chronic 
ostitis  of  the  hip  the  strumous  element  will  appear  in  the 
family  history.     This  may  not  be  found,  however,  but  it  will 
be  found  either  here  or  as  an  acquired   diathesis  in  the 
patient.     Furthermore,  the  neurotic  and  the  strumous  ele- 
ments may  be  combined  in  the  family  history,  and  the  for- 
mer may  even  stand    out   more   conspicuously  than   the 
latter. 

2.  In  both,  the  exciting  cause,  viz.,  trauma,  may  be  the 
same,  only  in  a  neurosis  the  effect  will,  as  a  rule,  follow  the 
more  speedily. 

3.  In   a  neurosis  pain  and  the  initial   lameness  appear 
simultaneously,  and  the  exacerbation  will  be  the  more  acute; 
in  chronic  ostitis  the  lameness  appears  first,  and  may  con- 
tinue a  long  time  before  an  exacerbation  appears. 

4.  In  a  neurosis  there  will  be  areas  of  hyperaesthesia  and 
paraesthesia  in  the  distribution  of  certain  nerve-branches, 
and  the  spine  will  also,  as  a  rule,  be  tender  in  the  region 
whence  the  nerves  are  given  off  ;  in  a  chronic  bone-disease 
there  is  seldom  any  hyperaesthesia  and  seldom  any  spinal 
tenderness,  while  the  pain  is  usually  in  the  distribution  of 
the  articular  branches  of  the  obturator. 

5.  In  a  neurosis  the  muscular  spasm  about  the  joint  will 
yield  readily  to  forced  movements;  while  in  a  chronic  bone- 
disease   the    contraction   becomes   the   greater  on    forced 
movement  of  the  limb.    In  other  words,  the  reflex  spasm  in 
the  one  yields  promptly  to  force;  in  the  other  it  is  increased 
by  force. 

6.  In  obscure  cases  a  brisk  counter-irritant  to  the  lumbar 
spine  will  promptly  relieve  a  neurosis,  and  will  have  very 
little  effect  on  a  chronic  bone-disease  of  the  hip. 

IV.  INFANTILE  SPINAL  PARALYSIS. 

One  would  never  think  of  confounding  an  infantile 
spinal  paralysis  with  the  first  stage  of  a  chronic  articular 
ostitis,  yet  it  has  been  done  by  men  who  pride  themselves, 
too,  on  their  diagnostic  ability.  And  then,  when  the  two 
diseases  are  compared  as  to  initial  symptoms,  it  does  not 
seem  so  unpardonable  an  error  to  mistake  the  one  for  the 
other.  The  ages  closely  correspond;  the  child,  in  a  sub- 


286  DISEASES  OF  THE  HIP. 

acute  spinal  paralysis,  totters  around  sometimes  two  or 
three  days  before  it  actually  gives  up  walking — there  can 
for  both  be  obtained  a  history  of  a  fall;  with  the  sudden' 
loss  of  power  comes  an  accentuation  of  the  pains  and  hyper- 
sesthesia  that  belong  to  a  poliomyelitis  in  its  active  stage; 
the  constitutional  disturbance  is  not  any  greater  frequently 
than  it  is  in  a  sharp  exacerbation  of  a  bone-disease  of  the 
hip.  I  must  confess  that  a  differential  diagnosis  is  not 
always  easy  to  make. 

In  the  fall  of  1874  a  male  child  two  and  a  half  years  of 
age  was  brought  to  me  for  examination.  He  seemed  to  be 
in  good  health,  but  was  cross  and  hard  to  control.  As  he 
stood  in  a  state  of  nudity  the  left  natis  was  flattened  a  little 
and  the  crease  was  lower  than  its  fellow.  Pressure  over  the 
trochanter  elicited  tenderness,  and  the  least  passive  motion 
of  the  limb  caused  the  child  to  cry  aloud  as  if  in  great  pain. 
On  measurement  there  was  only  a  shade  of  atrophy.  The 
skin  felt  cold  and  the  surface  thermometer  indicated  a 
slight  diminution  in  temperature.  There  was  lameness, 
but  as  the  child  walked  one  could  see  that  this  was  not  due 
to  the  action  of  the  muscles  in  protecting  the  hip;  the  gait 
was  unsteady;  a  tottering  at  the  knee  was  observed,  and 
after  walking  a  few  steps  the  limb  gave  way,  and  a  fall  was 
the  result.  The  electrical  examination  was  unsatisfactory, 
though  there  seemed  to  be  a  diminution  in  the  force  of  the 
faradic  contractions.  The  mother,  in  giving  the  history, 
stated  that  seven  nights  before,  without  any  provocation, 
so  far  as  she  knew,  the  child  became  a  little  peevish  and 
rested  badly;  slept  late,  however,  the  morning  following, 
and  walked  on  rising;  but  that  in  a  few  hours  she  noticed 
the  child  fall,  get  up,  and  after  awhile  fall  again;  that  he 
cried  and  moaned  the  second  night,  crying  the  more  if  the 
limb  was  moved;  that  he  was  very  lame  on  the  second  day; 
that  she  took  him  to  a  surgeon  of  acknowledged  ability — a 
man  whose  diagnosis  it  would  be  arrogance  to  question; 
that  after  a  long  examination  she  was  told  a  hip-splint 
must  be  procured  as  early  as  possible,  that  she  could  not 
meet  the  expense  of  the  apparatus,  and  that  she  comes  to 
me  now  two  days  later  hoping  to  get  the  needed  splint  free 
of  charge. 

In  the  family  history  a  maternal  aunt  is  reported  to 
have  died  of  hydrocephalus  at  the  age  of  eleven  years. 
The  history  of  the  invasion,  the  unsteadiness  of  the  gait, 
the  age  of  the  child,  suggested  to  my  mind  a  paralysis  of  a 


CHRONIC  ARTICULAR  OSTITIS :   DIAGNOSIS.       287 

group  of  muscles  of  the  limb,  and  to  this  diagnosis  I  ad- 
hered, especially  after  an  examination  on  the  day  following. 
Santonine  was  prescribed  in  order  to  remove  any  causes 
acting  reflexly  in  the  intestinal  canal.  No  results  were  ob- 
tained from  this,  and  after  one  or  two  more  visits  the 
child  was  lost  sight  of  for  nearly  a  year,  when  the  mother 
brought  him  back  to  be  treated  for  a  calcaneo-valgus,  par- 
alytic in  origin.  The  usual  electrical  treatment  with  the 
use  of  apparatus  was  employed,  and  the  deformity  alto- 
gether has  proven  most  intractable.  This  is  no  isolated 
case. 

Here  is  one  differing  a  little,  yet  the  result  is  the 
same.  I  have  them  both  under  treatment  at  present  for 
obstinate  calcaneus.  This  one  was  in  a  girl  two  years  of 
age,  seen  in  October,  1877.  She  was  seized  with  a  slight 
febrile  attack  five  weeks  before  coming  under  my  care. 
This  continued  five  days,  and  at  night  the  child  was  worse. 
During  that  period,  and  for  a  week  later,  the  patient  refused 
to  walk,  and,  if  placed  on  feet,  would  cry  as  if  in  severe 
pain.  Gradually  improved  for  a  week,  but  for  the  past 
two  weeks  the  improvement  had  been  less  marked.  Lat- 
terly has  had  no  pain  whatever  even  when  walking  freely. 
Patient  seen  twice  during  the  fourth  week  by  a  surgeon 
whom  the  profession  regards  as  an  expert  in  this  specialty, 
and  this  gentleman  writes  that,  after  careful  examinations, 
he  locates  the  disease  within  the  hip-joint,  as  he  finds  un- 
mistakable muscular  rigidity  about  the  hip.  He  makes  a 
differential  diagnosis,  however,  from  infantile  paralysis. 

I  found  the  nates  on  the  left  side  flattened  perceptibly,  the 
calf  one-half  inch  small;  motion  at  the  hip  joint  could  be 
made  to  the  normal  extent  in  all  directions  without  pain, 
though  there  seemed  to  be  a  little  resistance  to  complete 
abduction;  there  was  marked  diminution  of  the  tibialis  an- 
ticus  in  reaction  to  the  faradic  current.  There  was  lame- 
ness, but  this  was  not  like  that  due  to  disease  of  the  joint. 
My  diagnosis  was  infantile  spinal  paralysis  confined  to  a 
single  muscle  or  group  of  muscles,  and  treatment  instituted 
therefor.  There  was  in  April,  1878,  a  slight  degree  of  varus, 
the  limb  was  colder  than  its  fellow,  there  was  atrophy,  and 
the  child  would  become  lame  after  moderate  exertion — tires 
easily.  Neither  had  then,  nor  had  had  since  October,  any 
pain  whatever,  diurnal  or  nocturnal,  and  the  limb  could  be 
handled  without  any  discomfort. 

Unless  cases  like  these  two  be  carefully  studied,  one  can- 


DISEASES  OF  THE  HIP. 

hot  see  the  difference  between  such  and  a  chronic  articular 
ostitis  of  the  hip. 

One  afternoon  in  July,  1881,  a  case  was  sent  from  one  of 
the  general  hospitals,  and  although  I  had  little  time  for 
making  an  examination,  the  child  seemed  to  be  suffering 
so  much  and  so  helpless  withal,  that  I  did  go  over  the  case 
rather  hastily,  finding  what  I  took  to  be  an  early  and  an 
unusually  acute  exacerbation  in  a  chronic  bone  disease  ot 
the  hip.  The  patient  was  a  boy  three  years  of  age,  and  had 
been  four  days  lame  ;  in  fact,  on  this  day  he  was  quite  un- 
able to  walk.  The  child  stood  like  one  very  weak  from  an 
acute  illness.  There  was  limitation  to  complete  joint  move- 
ments in  abduction  and  in  rotation.  These  were  all  the 
signs  I  recorded,  and  while  I  placed  an  interrogation  point 
after  the  diagnosis,  I  somehow  felt  that  the  case  must  develop 
into  one  of  bone  disease.  The  patient  did  not  remain  in 
hospital,  and  the  next  time  I  had  an  opportunity  of  exam- 
ining the  case — two  months  later — I  found  paralysis  of  the 
quadriceps  femoris,  and  anterior  and  posterior  tibial  groups. 

It  will  be  seen  that  there  are  certain  well-defined  differ- 
ences, notwithstanding  the  close  similarity — 

1.  The  limp  in  a  spinal  paralysis  is  not  a  limp  that  is  as- 
sumed to  protect  the  joint.     The  child  is  lame  because  of 
the  weakness  of  the  support;  in  bone  disease  the  muscles 
contract  to  protect  the  joint  and  every  step  is  taken  with 
this  protection  in  view.     One  is  a  tottering  gait,  the  other 
is  a  stiff  gait. 

2.  In  one  there  is  no  reflex  muscular  spasm  about  the 
joint ;  in  the  other  a  careful  search  will  find  one  or  more 
groups  contracting  on  passive  movement  when  carried  near 
extreme  limits. 

3.  The  galvanic  current,  after  the  first  week  at  least,  will 
give  the  degeneration  reaction  in  a  spinal  paralysis  ;  in  the 
other  the  galvanic  current  will  give  the  normal  formula. 
The   degeneration  reaction  is  the  reversal  of  the  normal 
formula.     When  the  more  vigorous  contraction  of  a  muscle 
or  group  of  muscles  takes  place  at  the  time  the  current  is 
closed  by  placing  over  the   same  the  electrode  from  the 
negative  pole — this  is  called  the  normal  formula — and  is 
expressed  by  the  signs  C.  C.  C.  >  A.  C.  C.  which  being  in- 
terpreted is:    cathodal  closure  contraction  is  greater  than 
anodal  closure  contraction. 

4.  The  faradic  reaction  is  lost  in  muscles  paralyzed  from 
an  infantile  spinal  paralysis  within  the  first  week ;  it  is 


CHRONIC  ARTICULAR   OSTITIS  :  DIAGNOSIS.       289 

merely  diminished  if  at  all  impaired  in  the  early  stage  of  a 
chronic  articular  ostitis.  This  latter  is  the  more  available 
test  for  the  general  practitioner. 

V.  PERIARTHRITIS. 

It  is  only  in  the  very  early  stage  of  a  periarthritis  that 
one  need  experience  much  difficulty  in  making  a  diagnosis. 
After  the  infiltration  has  presented  the  signs  become  suffi- 
ciently clear.  It  must  be  remembered  that  I  am  now  speak- 
ing of  the  phlegmonous  inflammations  around  the  joint. 
Children  as  a  rule  never  have  the  fibrous  form,  but  this  oc- 
curs in  the  adult  occasionally,  and  the  diagnosis  is  made 
then  by  exclusion. 

Take  as  a  very  good  illustration  of  the  course  a  periar- 
thritis of  childhood,  the  following,  in  a  boy  three  years  of 
age,  who  came  under  my  observation  in  August,  1879.  In  the 
early  part  of  July  he  had  an  attack  of  rubeola  and  was  con- 
fined to  bed  for  ten  days.  On  leaving  his  bed  no  lameness 
was  discovered,  in  fact  he  walked  as  well  as  he  ever  did, 
until  a  week  had  elapsed,  when  he  began  without  known 
provocation,  to  favor  the  right  side  in  walking.  A  few  days 
later  pain  became  a  marked  symptom,  and  the  limb  would 
not  tolerate  any  handling.  The  father  was  referred  to  the 
hospital  by  his  medical  adviser  to  have  the  child  treated 
for  "  hip-disease."  I  found  an  axillary  temperature  of 
101.5°,  a  pulse  of  132,  and  an  extreme  degree  of  irritability 
in  the  patient.  It  was  difficult  to  secure  a  satisfactory  ex- 
amination on  account  of  the  apparent  tenderness  of  the 
limb,  yet  by  a  little  perseverance  I  learned  that  the  thigh 
could  not  be  completely  extended,  flexed  or  rotated,  and 
that  the  position  assumed  in  standing  was  that  of  the  first 
stage  at  the  height  of  an  acute  exacerbation.  There  was 
extensive  infiltration  about  the  hip  and  around  the  upper 
third  of  the  thigh,  though  no  fluctuation  could  be  detected. 

The  acuteness  of  the  attack,  the  rapid  development  of 
signs,  and  the  constitutional  disturbance  enabled  me  to  diag- 
nosticate a  periarthritis.  The  subsequent  progress  of  the 
case  fully  confirmed  the  diagnosis  made,  and  in  less  than 
two  months  a  cure  was  fully  established. 

In  February,  1879,  I  saw  a  boy  nine  years  of  age,  two 
months  after  his  first  lameness  was  observed.  An  exacer- 
bation had  followed  soon  after  the  beginning  of  the  lame- 
ness, and  the  second  stage  was  already  present  at  the  time. 


DISEASES  OF  THE  HIP. 

I  made  my  examination.  There  was  an  apparent  lengthen- 
ing of  one  inch,  and  the  natis  and  thigh  were  very  promi- 
nent by  reason  of  extensive  infiltration.  I  found  it  difficult, 
however,  to  flex  the  thigh  to  90°  or  to  extend  to  135.°  All 
the  other  movements  were  resisted  and  the  diagnosis  was 
made  without  any  hesitation  of  chronic  articular  ostitis  of 
the  hip.  The  case  went  rapidly  through  the  various  stages 
The  temptation  to  cite  further  illustrative  cases  is  very 
strong,  but  the  chapter  on  the  clinical  history  of  bone  lesion 
is  already  full  enough  to  convince  any  one  that  while  cer- 
tain cases  may  seem  like  acute  processes,  a  little  more  study 
of  details  will  bring  out  the  chronic  nature — the  slow  pro- 
cesses of  the  same.  It  remains  now  to  sum  up  the  points,  as 
my  plan  is,  of  differential  diagnosis,  premising,  however 
a  few  points  of  similarity — 

1.  Both     plegmonous     coxo-femoral     periarthritis    and 
chronic  articular  ostitis  of  the  hip  occur  at  about  the  same 
period  of  life. 

2.  Both  occur  in  strumous  subjects,  yet  the  former  is 
more  frequent  than  the  latter  in  non-strumous  subjects. 

3.  Both  may  begin  with  lameness  without  accompanying 
pain. 

4.  The  limp  of  the  two  may  be  identical. 
Differentially,  we  have  :  i.     Pain    and  acute  symptoms 

within  the  first  few  days  in  a  periarthritis  ;  these  are   the 
exceptions  in  a  chronic  articular  ostitis. 

2.  In  the  one  there  is  extra  heat  and  superficial  tender- 
ness ;  in  the  other  these  signs  are  so  insignificant  as  not  to 
be  readily  appreciable. 

3.  In  the  one  tumefaction  appears  as  a  rule  within  the 
first  fortnight ;  in  the  other  several  weeks,  and  months  even, 
elapse  before  any  tumefaction  presents. 

4.  In  an  early  periarthritis  those  movements  are  li  mited 
whose  mechanical  execution  is  interfered  with  by  inflam- 
matory processes,   and   the  explanation   is  comparatively 
easy:  in  an  early  ostitis  the  limitation  is  purely  reflex  there 
being  no  mechanical  obstructions  appreciable,  and  one  is  at 
a  loss   to  explain  why  certain  groups  of  muscles  should 
be  excited  to  spasm  or  resistance  by  attempts  at  passive 
motion. 

5.  Palpation   will  detect   a   lesion   in   the    periarticular 
tissue  in  the  one;  in  the  other  palpation  will  serve  only  a 
negative  purpose. 

6.  In  the  one  the  constitutional  symptoms  are  often  very 


CHRONIC  ARTICULAR  OSTITIS  :   DIAGNOSIS.       2QI 

marked  ;  in  the  other  there  are,  as  a  rule,  no  constitutional 
disturbances  in  the  early  stage. 

7.  In  the  one  the  sleep  is  disturbed  by  moaning  and  rest- 
lessness; in  the  other  the  characteristic  night  symptom  is 
the  ostitic  cry. 

8.  In  the  one  there  is  no  atrophy  of  the  limb;  in  the  other 
this  is  an  early  sign. 

9.  Finally,  if  an  immediate  diagnosis  be  not  required,  re- 
peated observations,  extending  over  a  fortnight,  will  clear 
up  all  points  of  differentiation. 

VI.  BURSITIS. 

The  comparative  infrequency  of  a  simple  uncomplicated 
bursitis,  makes  it  very  improbable  that  one  will  have  occa- 
sion to  differentiate  between  this  lesion  and  a  chronic 
articular  ostitis.  The  mere  fact,  however,  that  such  lesions 
do  occur,  and  the  fact  that  they  yield  so  promptly  to  reme- 
dial measures,  make  it  extremely  important  that  one  should 
be  able  to  effect  a  differential  diagnosis. 

The  signs  are  usually  well  enough  marked  if  one  look 
over  the  case  with  an  unbiased  mind.  The  average  prac- 
titioner is  so  prone  to  regard  every  case  of  lameness  as  one 
of  "  hip-disease,"  that  he  gets,  not  only  the  history,  but  the 
symptoms  or  signs  of  the  disease  without  any  difficulty.  I 
remember  with  a  good  deal  of  chagrin  a  case  of  infantile 
spinal  paralysis  in  which  I  got  an  excellent  history,  ten 
years  ago,  of  chronic  disease  of  the  hip-joint ;  and  what 
was  worse,  I  kept  him  under  treatment  for  many  months 
before  I  recognized  my  error. 

Ordinarily  a  bursitis  presents  very  few  signs  of  an  exag- 
gerated type.  The  lameness  is  scarcely  appreciable,  even 
at  any  time  during  the  progress  of  the  disease,  the  exacer- 
bations are  usually  mild  in  character,  and  the  constitutional 
disturbance  is  comparatively  insignificant.  Take,  for  in- 
stance, the  case  reported  on  page  in  of  this  work.  The 
bursa  involved  lay  under  the  gluteus  maximus  and  over 
the  trochanter  major.  At  times  separated  by  long  inter- 
vals, the  inconvenience  was  so  slight  even  then,  that  the 
patient  did  not  care  much  for  treatment.  He  was  naturally 
annoyed  by  the  little  pain  on  walking  and  feared  an  out- 
burst of  joint-symptoms,  yet  as  the  years  went  by  his  fears 
became  of  less  consequence  and  he  gradually  lost  interest 
in  his  case,  The  lameness,  it  is  true,  was  nearly  always 


292  DISEASES  OF  THE  HIP. 

yuch  as  one  would  expect  to  find  in  a  chronic  bone  disease 
whose  evolution  was  exceedingly  slow.  During  the  exa- 
cerbation he  complained  only  of  a  moderately  severe  pain, 
and  was  not  sufficiently  crippled  as  to  think  of  giving  up 
his  work. 

Then,  again,  the  girl  whose  case  is  reported  on  page  112 
stood  with  limbs  parallel  and  the  lameness  was  so  slight  as 
to  lose  its  significance.  The  symptoms  were  mild  in  type 
and  the  patient  would  scarcely  be  recognized  as  a  patient. 
The  presence  of  the  sub-gluteal  tumor  was  all  that  occa- 
sioned any  anxiety. 

The  ilio-psoas  bursa,  in  the  case  of  the  girl  reported  on 
pages  117  and  118,  proved  in  the  end  far  more  serious  than 
any  with  which  I  have  had  to  deal ;  yet  her  acute  and  dis- 
tressing symptoms  were  not  due  to  the  bursitis  as  a  bur- 
sitis.  It  was  after  repeated  invasions  of  the  articular  cavity 
that  the  points  in  differential  diagnosis  proved  of  no  avail. 
All  the  time  prior  to  the  establishment  of  the  joint  lesion, 
the  signs  and  symptoms  of  the  simple  bursitis  were  clear 
enough  for  diagnosis.  To  differentiate,  then,  an  uncompli- 
cated bursitis  from  a  chronic  bone  lesion  in  the  immediate 
Vicinity  of  the  hip,  it  must  be  remembered  that: 

1.  The  exciting  cause  in  a  bursitis  will  be  the  sooner  fol- 
lowed by  visible  effects  in  the  soft  parts  about  the  hip. 

2.  The  history  of  lameness  in  a  bursitis  is  that  of  exa- 
cerbations with  complete  remissions ;  while  in  a  chronic 
ostitis  the  remission  is  never  complete. 

3.  A  primary  bursitis  seldom  invades  with  inflammatory 
products    adjacent   tissues;   while   a   bursitis   induced   by 
proximity  to  bone-disease,  is  surrounded  by  infiltrated  tis- 
sues to  such  an  extent  that  the  bursa  itself  can  with  diffi- 
culty be  appreciated.     In  other  words,  the  one  is  easy  of 
recognition  by  palpation,  the  other  is  a  part  of  a  general 
tumefaction. 

4.  In  a  bursitis  the  joint  is  never  locked  by  reflex  muscu- 
lar spasm;  while  in  an  ostitis  this  is  a  common  condition. 

5.  A  bursitis  rarely  occurs  prior  to  the  seventh  year;  a 
chronic  ostitis  more  frequently  occurs  before  this  age. 

6.  A  hypodermic  needle  will  reveal  the  existence  of  serum 
in  a  bursal  tumor,  of  sero-pus,  or  pus  in  a  residual  abscess. 

VII.  ACUTE  SYNOVITIS. 
In  Chapter  VIII.  I  have  already  shown  that  when  the 


CHRONIC  ARTICULAR  OSTITIS :  DIAGNOSIS.       293 

synovial  membrane  of  the  hip  is  primarily  inflamed  the 
process  is  acute,  and  is  the  more  common  between  the  ages 
of  eight  and  fifteen  years.  I  have  also  combatted  the  theory 
that  articular  ostitis  begins  as  a  synovitis,  and  while  I  am 
prepared  to  admit  that  exceptionally  such  bone  lesions  be- 
gin in  this  way,  I  am  all  the  more  fully  convinced  that  the 
initial  synovitis  can  be  easily  recognized,  and  if  promptly 
recognized,  be  controlled  before  destructive  changes  occur 
in  the  osseous  tissue.  Apart,  however,  from  therapeutic  con- 
siderations, the  necessity  for  discrimination  is  still  greater 
from  a  prognostic  standpoint;  for  a  synovitis,  as  a  rule, 
will  resolve,  even  if  no  treatment  be  employed,  and  this 
fact  in  connection  with  a  chronic  ostitis  of  the  hip  is  but 
too  clearly  demonstrated  as  a  fact,  viz.:  that  resolution  does 
not,  as  a  rule,  take  place  under  the  best  form  of  treatment 
known  to  the  profession.  I  shall  be  pardoned,  then,  if  I 
insist  strongly  in  detail  on  the  points  of  difference. 

The  following  case,  from  the  signs  found,  led  me  to  re- 
gard it  as  one  primarily  of  synovitis.  It  was  in  a  girl  aged 
ten  years,  who  was  fairly  nourished,  and  whose  limb  as  she 
stood,  was  in  eversion  and  slight  outward  rotation.  There 
seemed  to  be  some  tension  of  the  nates  and  the  joint  ten- 
derness was  very  marked,  the  least  pressure  of  the  head  into 
the  acetabulum  exciting  sharp  pains  in  the  joint  and  in  the 
knee  branches  of  the  obturator.  On  rotating  the  limb,  pain 
was  referred  to  the  knee.  The  thigh  could  be  flexed  to  the 
full  extent  and  extended  to  the  extreme  normal  limit  with 
ease.  On  abduction  she  complained  of  pain  and  the  move- 
ment was  checked  by  reflex  spasm  of  the  adductors.  There 
was  no  atrophy  in  any  portion  of  the  limb.  There  was  con- 
siderable tenderness  of  the  spine.  I  found  a  phthisical  ele- 
ment in  the  family  history,  and  the  present  disease  began 
five  weeks  before  with  lameness  and  lordosis.  It  was  nearly 
a  fortnight  before  pain  developed.  She  then  began  to 
scream  at  night.  In  other  words,  there  could  not  have 
been  a  better  history  of  a  chronic  ostitis,  and  the  subse- 
quent history  proved  this  to  be  a  typical  case.  Her  first 
exacerbation,  as  is  common  in  patients  of  that  age,  came 
on  early,  and  I  chanced  to  examine  her  for  the  first  time  as 
the  exacerbation  was  subsiding. 

In  the  early  years  of  my  hospital  service  I  met  with  a 
case  which  puzzled  me  no  little.  It  was  in  a  girl  seven  or 
eight  years  of  age  who  would  come  into  the  hospital  in  the 
most  acute  stage  of  "  hip-disease/'  and  under  a  little  ex- 


294  DISEASES   OF  THE   HIP. 

pectant  treatment  make  a  prompt  recovery.  This  was  re- 
peated twice  to  my  knowledge.  Here  remissions  were  so 
complete  that  I  could  not  regard  it  as  true  bone-disease. 
When  she  first  came  into  hospital,  it  was  in  1870,  and  her 
history,  as  I  find  it  recorded,  was  that  she  had  a  severe  fall 
six  months  before  her  admission,  and  began  fourteen  days 
afterwards  to  walk  lame.  Shortly  after  the  beginning  of 
the  lameness  she  had  severe  pains  attended  with  screaming 
at  night  and  loss  of  flesh.  All  these  acute  symptoms  had 
subsided  on  her  admission,  yet  she  had  decided  joint-ten- 
derness in  response  to  the  different  tests.  There  was  no 
resistance,  or,  at  least  very  little  to  normal  movements.  No 
diagnosis  was  recorded;  a  simple  liniment  was  employed 
and  a  month  later  a  careful  examination  failed  to  detect  any 
symptoms  or  signs  of  disease. 

A  year  and  a  half  elapsed  and  she  was  readmitted  totally 
unable  to  walk,  and  standing,  when  it  \vas  possible  to  in- 
duce her  to  stand,  almost  entirely  on  the  left  limb  (the 
right  was  the  one  fromerly  affected  as  well  as  now)  while 
this  was  advanced  and  everted.  The  natis  was  broad  yet 
free  of  infiltration,  while  the  inguinal  glands  were  enlarged. 
Flexion  and  adduction  caused  great  pain,  and  the  oppos- 
ing muscles  were  very  tense.  She  seemed  to  be  suffering 
very  acutely,  and  her  symptoms  were  only  of  about  ten 
days'  standing.  She  was  blistered  and  poulticed  quite 
freely,  and  within  a  week  all  acute  symptoms  had  sub- 
sided, and  seven  weeks  from  the  date  of  this  readmission 
she  was  again  discharged  cured. 

I  have  seen  the  girl  from  time  to  time,  growing  up  into 
womanhood,  and  she  has  never  walked  lame  or  shown  any 
disposition  to  relapse  since  the  date  of  last  discharge.  I 
cannot  do  other  than  regard  this  as  a  recurring  synovitis 
from  trauma,  although  my  notes  are  not  as  full  as  I  should 
like.  Still,  the  course  of  the  disease  in  the  two  instances 
strengthens  me  in  the  belief  in  my  diagnosis.  The  cases 
reported  in  the  chapter  specially  devoted  to  this  subject 
are  much  more  pertinent,  and  a  study  of  them  will  give  one 
a  complete  picture  of  this  ailment.  The  differential  diag- 
nosis can  be  made  by  remembering  that: 

1.  In  a  synovitis  the  pain  will  be  coincidental  with  the 
lameness,  and  the  invasion  will  be  sharp  and  clear;  in  an 
ostitis  the  lameness  precedes  the  pain,  and  the  invasion  is 
seldom,  if  ever,  sharply  defined. 

2.  In  synovitis  the  lameness  speedily  becomes  so  great 


CHRONIC  ARTICULAR  OSTITIS  :  DIAGNOSIS.       295 

that  locomotion  is  impossible;  in  ostitis  the  reverse  is  the 
rule. 

3.  Synovitis  occurs  after  the  eighth  year  of  life;  chronic 
ostitis  before  this  age. 

4.  Joint-tenderness  is  found  in  synovitis;  and  is  not  found 
as  a  rule  in  chronic  ostitis  of  the  hip. 

5.  In  synovitis  there  will  be  no  periarticular  infiltration 
or  bone-tenderness;    in  ostitis  the  bone-tenderness  is  an 
early  sign,  and  infiltration  will  be  recognized  as  the  second 
stage  approaches. 

6.  In  synovitis  atrophy  is  the  exception;  in  ostitis,  the 
rule. 

^.  The  position  of  the  limb  in  synovitis  is,  as  a  rule,  rota- 
tion outward,  eversion  and  apparent  elongation;  in  an  early 
ostitis  it  is  parallel,  or  nearly  so,  with  its  fellow. 


VIII.  PERIOSTITIS  OF  THE  HIP. 

Taking  a  simple  periostitis  and  a  periosteal  sarcoma,  a 
correct  diagnosis  become  very  important.  The  cases  of 
periostitis  generally  make  a  good  recovery  even  if  suppura- 
tion takes  place.  The  early  history  of  a  chronic  periostitis 
does  not  differ  materially  from  the  history  of  a  chronic  ar- 
ticular ostitis.  In  both  the  lameness  is  the  first  notable 
sign;  in  both  there  is  bone-tenderness,  and  in  both  the  ex- 
citing cause  may  be  a  contusion. 

In  addition  to  the  cases  of  periostitis  already  reported, 
the  following  may  be  of  interest:  Take  that  of  a  girl  aged 
ten  years,  whom  I  saw  in  the  spring  of  1876.  A  pretty 
clear  history  was  given  of  a  severe  fall  a  year  previously, 
and  she  walked  lame  immediately  thereafter.  Bye  and  bye 
the  lameness  grew  less  marked,  yet  the  pain  was  a  constant 
symptom,  and  this  was  referred  to  the  periarticular  tissues 
about  the  trochanter.  She  had  always  suffered  more  at 
night.  She  was  well  nourished,  and  my  examination  re- 
vealed the  following  points:  Advancing  of  the  limb  and 
eversion  of  the  foot  as  she  stood;  flattening  of  the  natis, 
change  in  the  crease,  and  a  little  thickening  apparently  of 
the  periosteum  over  trochanter,  with  much  tenderness  on 
pressure  in  this  locality;  a  marked  limp,  in  which  the  toes 
and  ball  only  came  in  contact  with  the  floor;  resistance  to 
passive  flexion  beyond  135°,  to  abduction  and  to  rotation, 
but  none  to  extension;  no  atrophy  or  shortening.  At  that 


296  DISEASES  OF  THE  HIP. 

time  I  was  at  a  loss  for  a  diagnosis.  Here  were  many  of 
the  characteristic  signs  of  a  central  ostitis,  and  then,  on  the 
other  hand,  there  was  the  clear  history  of  the  fall,  the 
localized  tenderness,  and  the  continuous  pain,  but  especially 
the  absence  of  shortening  and  atrophy  after  a  year's  dura- 
tion. The  most  plausible  lesion  was  a  periostitis,  and  the 
parts  were  blistered.  Before  a  month  had  elapsed  there  was 
scarcely  any  sign  of  disease,  and  at  the  end  of  two  months 
she  was  discharged  cured.  I  found  no  pain,  no  limp,  no 
change  in  natis,  and  no  resistance  to  any  normal  movement 
of  the  hip. 

Jn  the  summer  of  1882  a  girl  eight  years  of  age  presented 
with  a  lesion  about  the  left  hip,  and  a  member  of  the  staff, 
very  good  in  diagnosis,  regarded  it,  after  a  careful  examina- 
tion, as  a  chronic  articular  ostitis.  The  limbs  were  of  equal 
length,  yet  there  was  one  inch  atrophy  of  the  thigh  and  a 
fluctuating  tumor  in  the  upper  third.  The  joint  was  free  as 
to  movements  and  the  articular  surfaces  were  smooth.  She 
limped  quite  characteristically,  and  the  history  was  that  she 
had  been  lame  for  nearly  a  year,  that  it  followed  a  severe 
fall  down  seven  or  eight  steps,  and  that  the  lameness  was 
preceded  by  pain.  An  opportunity  was  not  afforded  for 
another  examination  until  a  year  afterwards,  when  I  got  a 
clearer  history  of  pain  at  first,  and  very  gradual  lameness 
subsequently.  The  abscess  had  opened  spontaneously, 
and  two  or  three  open  sinues  lay  around  the  trochanter. 
The  atrophy  was  the  same  as  at  last  observation,  but  I  made 
out  now  a  half-inch  shortening.  I  could  flex  easily  to  45° 
and  extend  to  180°,  while  the  other  movements  were  very 
nearly  perfect.  The  limbs  were  parallel,  and  the  limp  was 
very  slight.  In  other  words,  no  joint  lesion  could  be  dis- 
covered, and  the  diagnosis  of  a  periostitis  was  confirmed. 

A  reiteration  in  this  connection  of  the  clinical  fact  that  in 
children  over  eight  years  of  age  articular  ostitis  often  be- 
gins as  a  periostitis,  cannot  be  out  of  place.  In  such  cases, 
however,  early  symptoms  and  early  signs  are  usually  suffi- 
ciently clear  to  enable  one  to  make  a  diagnosis  of  the  in- 
itial lesion. 

To  enumerate  the  points  in  differentiation: 

i.  In  the  history  of  a  periostitis  pain  and  soreness  pre- 
cede the  limp,  and  the  pain  is  confined  to  a  distinct  area 
without  the  joint;  in  the  history  of  a  chronic  ostitis  lame- 
ness precedes  the  pain  by  a  distinct  interval,  and  the  pain 
when  it  does  make  itself  manifest  is  not  confined  to  any 


CHRONIC  ARTICULAR  OSTITIS  :  DIAGNOSIS.       297 

special  locality,  but  may  be  felt  at  the  same  time  in  the  hip 
joint  and  in  the  knee. 

2.  In  a  periostitis  the  trauma  is  followed  by  clear  and 
unmistakable  signs;  in  an  ostitis  the  signs  are  aught  but  clear 
and  unmistakable.     In  other  words,  if  one  is  told  that  the 
whole  trouble  came  from  a  fall  or  a  blow  there  will  be  no 
trouble  in  finding  signs  of  the  same  if  the  lesion  be  a  peri- 
ostitis, but  one  will  have  to  search   frequently  in  vain  for 
any  tangible  signs  if  the  lesion  be  a  chronic  ostitis. 

3.  In  a  periostitis  the  muscular  resistance  to  passive  move- 
ment will  rarely  be  reflex,  but  purely  mechanical,  i.e.,  those 
muscles  which  are  connected  with  the  seat  of  disease  will 
respond  less  freely  to  attempts  at  active  or  passive  motion; 
in  an  ostitis  the  reflex  muscular  spasm  in  adductors  and 
rotators  is  usually  present  early  in  the  case. 

4.  Palpation  in  a  periostitis  will   detect   thickness  and 
tenderness  over  a  given  area;  palpation  in  an  early  ostitis 
will  only  exceptionally  detect  any  thickening  or  tenderness, 
and  if  such  does  exist  it  will  be  found  near  the  digital  fossa. 

5.  The  lameness  in  a  periostitis  is  pretty  uniform,  and 
rarely  reaches  the  point  when  walking  is  impossible;  during 
the   exacerbation   of   an   ostitis  the  patient   is  frequently 
totally  unable  to  walk. 

These  are  the  chief  points,  and  others  will  suggest  them- 
selves in  a  doubtful  case  if  the  proper  care  be  employed  in 
an  examination. 

In  differentiating  a  periosteal  sarcoma  from  a  central 
ostitis  about  the  hip,  a  few  points  are  necessary,  such  as, 
i.  The  uniform  periosteal  enlargement  in  a  sarcoma — an 
enlargement  that  takes  in  the  whole  circumference  of  the 
bone;  and  2,  the  freedom  of  joint  movements.  This  subject 
has  been  treated  at  considerable  length  in  that  portion  of 
Chapter  X.  which  deals  with  malignant  diseases  of  the  hip. 

IX.  OSTITIS  OF  THE  ILIUM,  INCLUDING  SACRO-!LIAC  DISEASE. 

The  current  pathology  of  joint  diseases,  viz.,  an  initial 
lesion  of  the  soft  parts  gradually  extending  to  the  hard 
tissues  is  responsible  for  "  Sacro-iliac  Disease."  It  would 
be  infinitely  better,  I  think,  to  discard  the  name  from  our 
nosology,  and  employ  the  term  ostitis,  or  necrosis,  or  caries 
of  the  sacrum  or  ilium.  This  articulation  never  in  my  own 
experience  suffers  primarily,  and  it  is  so  well  protected,  so 
well  fixed  by  its  very  construction  that  when  it  does  become 
diseased  the  gravity  of  the  lesion  is  not  enhanced, 


298  DISEASES  OF  THE  HIP. 

It  has  been  my  observation  that  many  cases  diagnosticated 
as  primary  sacro-iliac  disease,  have  proved  to  be  caries  of  the 
lower  lumbar  vertebrae  and  sacrum,  ostitis  of  the  ilium,  or 
chronic  articular  ostitis  of  the  hip.  I  have  myself  diagnos- 
ticated many  such,  and  ultimately  find  just  what  I  have 
stated.  I  have  notes,  too,  of  cases  presented  at  clinics 
as  typical  of  sacro-iliac  disease  that  are  now  undoubted 
cases  of  bone  disease  of  the  hip  in  the  advanced  stage.  It 
is  difficult  to  place  them  on  record  without  being  personal, 
yet  I  am  just  as  firmly  convinced  that  the  disease  in  question 
is  one  of  the  rarest  of  all  the  so-called  joint  diseases.  Time 
and  again  I  have  followed  up  cases  that  have  developed 
abscesses,  and  have  been  operated  upon  in  the  general 
hospitals  with  the  idea  of  finding  this  articulation  involved, 
and  I  can  not  now  recall  a  single  case  where  the  operator 
was  willing  to  put  himself  on  record  as  finding  the  lesion 
he  suspected.  I  am  willing  to  go  thus  far  in  a  statement, 
viz.,  that  I  have  been  often  asked  by  the  general  surgeon 
whether  sacro-iliac  disease  is  a  myth  or  not.  In  searching 
the  records  of  nearly  twelve  hundred  cases  of  disease  in  the 
neighborhood  of  the  coxo-femoral  articulation  I  have  had 
the  opportunity  of  examining,  I  am  unable  to  find  a  single 
case  that  I  should  like  to  place  on  record  as  one  by  which 
I  could  stand. 

I  trust  that  I  shall  not  in  these  remarks  be  regarded  in 
the  light  of  disbeliever  in  the  existence  of  a  lesion  at  this 
joint.  I  am  too  well  aware  that  the  many  excellent  ob- 
servers, both  in  my  own  country  and  in  other  countries, 
have  honestly  reported  cases  wherein  the  evidence  seems 
overwhelming.  Only  I  am  desirous  of  stating  my  convic- 
tions (simply  for  what  they  are  worth)  on  the  following 
points: 

1.  That  a  primary  arthritis  of  the  sacro-iliac  synchon- 
drosis  is,  to  my  mind,  unproven. 

2.  That  the  cases  recorded,  and  in  many  instances  well 
recorded,    are    secondary   to   inflammatory    bone    lesions 
within  the  vicinity  of  this  articulation. 

3.  That  a  destructive  bone  lesion  of  the  pelvis  is  not 
rendered  any  more  grave  as  to  prognosis  by  the  co-existence 
of  a  sacro-iliac  arthritis. 

4.  That  for  practical  purposes  and  for  diagnostic  pur- 
poses, it  makes  little  difference  whether  a  lesion  of   this 
joint  be  recognized  as  a  distinct  entity  or  not. 

I  am  unprepared  to  accept  the  dictum  of  any  man  regard- 


CHRONIC  ARTICULAR  OSTITIS:   DIAGNOSIS.       299 

ing  the  existence  of  such  cases  unless  he  will  so  report  the 
case  in  all  its  details  that  I  can  make  my  own  diagnosis 
from  the  symptoms  and  signs  the  given  case  presents. 

We  must  remember  that  the  acetabulum  is  occasionally 
perforated  at  an  early  stage  of  ostitis  of  the  hip,  and  that 
the  pus  sometimes  burrows  along  the  internal  iliac  fossa, 
giving  rise  to  symptoms  that  would  point  to  disease  'at  or 
near  this  articulation.  We  must  further  remember  that  a 
neurosis  may  give  rise  to  symptoms  of  disease  in  this  neigh- 
borhood. As  above  remarked,  my  own  cases  of  supposed 
disease  here  leave  me  still  looking  for  an  unmistakable  in- 
stance. 

Take  the  case,  for  instance,  I  have  already  reported  in  the 
chapter  on  Pathology  (page  179)  as  one  of  diaphyso-epiphy- 
sial  ostitis  of  one  side  and  caries  of  the  acetabulum  of  the 
other.  This  girl,  it  will  be  remembered,  had  "  lameness" 
as  a  "  constant"  sign,  had  "  tenderness  over  the  sacro-iliac 
synchondrosis"  on  several  examinations,  had  "  motion  at  the 
hip-joint  on  the  affected  (?)  side,  free,  smooth  and  painless 
when  the  pelvis  was  fixed,  except  when  carried  to  extreme 
flexion  and  rotation,"  had  "  apparent  lengthening  of  the 
limb."  After  several  examinations,  one  of  which  I  shall 
presently  copy  verbatim  from  my  notes,  I  made  out  a  diag- 
nosis unhesitatingly  of  sacro-ilia  disease,  left  side.  The 
quotation  points  above  inserted  are  placed  about  symptoms 
given  by  Dr.  Poore  in  a  classical  article  published  in  the 
American  Journal  of  the  Medical  Sciences  for  January,  1878. 
I  shall  take  occasion  again  to  refer  to  this  article.  In  the 
case  I  am  now  analyzing  I  noted  January  17,  1879,  in  my 
case-book  the  following:  "The  mother  insisted  on  the  pain 
being  in  the  left  gluteal  region.  Pressure  here,  especially 
over  the  left  sacro-iliac  junction,  gives  pain  unmistakably. 
This,  also,  on  crowding  the  alse  of  the  pelvis  together.  No 
pain  on  motion  at  the  left  hip.  As  the  child  lay  on  the  bed 
the  stocking  was  pulled  on  easily  without  any  pain  or 
difficulty.  The  heel  was  struck  hard,  and  the  child  only 
laughed.  She  could  not  be  induced  to  stoop  to  pick  up 
anything,  complaining  of  pain  at  the  left  knee  on  the  at- 
tempt. Motion  of  the  spine  above  the  sacrum,  however, 
could  be  made  without  pain.  As  she  stands  the  left  limb 
was  apparently  lengthened;  no  real  difference  by  measure- 
ment. A  careful  examinanation  is  made  as  to  a  possible 
rheumatic  history  in  the  family,  but  nothing  is  found  on 
cither  side."  Dr.  Poore  saw  the  case  next  day  with  me, 


300  DISEASES  OF  THE  HIP. 

and  after  a  thorough  examination,  without  an  anaesthetic, 
confirmed  my  diagnosis  of  sacro-iliac  disease.  The  subse- 
quent course  of  the  case  and  the  lesions  found  post-mortem 
are  already  a  part  of  history. 

Again,  in  the  case  of  a  boy,  reported  in  the  chapter  on 
Periarthritis,  pages  104  and  105, 1  fancied  I  had  a  sacro-iliac 
disease.  I  found  decided  tenderness  on  pressure  in  the 
neighborhood  of  the  sacro-iliac  synchondrosis,  resistance 
to  abduction  and  pain  in  groin  and  about  gluteal  region. 
Then  fourteen  months  later  I  found  the  sac  of  an  abscess  in 
this  locality.  Dr.  Bull  found,  on  operation,  a  sequestrum 
of  bone  near  the  synchondrosis,  but  no  sacro-iliac  disease. 

On  account  of  Dr.  Poore's  accuracy  and  honesty  of  ob- 
servation, I  very  much  regret  that  in  his  elaborate  paper  he 
has  only  two  cases  of  his  own  to  analyze.  I  am  by  no 
means  convinced  that  the  first  one  he  reports  belongs  to 
this  category,  as  it  passed  from  observation  before  the 
diagnosis  could  be  confirmed  either  by  clinical  features  or 
by  post  mortem  examination.  It  is  reported,  however,  so 
faithfully  and  with  such  detail  that  any  one  at  all  familiar 
with  the  normal  and  abnormal  types  of  a  chronic  articular 
ostitis,  on  a  careful  reading,  would  be  very  prone  to  make 
a  diagnosis  of  ostitis  of  the  hip.  The  second  case  is  more 
to  the  point,  and  corresponds  closely  with  the  clinical 
history  of  the  disease.  From  the  perforation  of  the  pelvis, 
however,  it  would  seem  that  the  sacro-iliac  arthritis  was 
secondary  to  the  bone  lesion. 

He  analyzes  fifty-eight  cases  collected  from  foreign  and 
domestic  journals,  including  his  own  in  the  analysis.  As  I 
have  already  confessed,  I  have  no  clinical  experience  in  this 
disease,  and  I  shall  only  too  gladly  base  my  subsequent 
remarks  on  the  conclusion  Dr.  Poore  has  reached. 

First,  as  to  the  pathology.  In  twenty-two  cases  examined 
post  mortem  thirteen  seemed  to  have  been  cases  in  which 
the  lesion  was  primary,  and  nine  secondary.  Of  this  nine, 
five  were  secondary  to  disease  of  the  lumbar  vertebrae;  in 
three  the  disease  was  subsequent  to  a  phlegmonous  inflam- 
mation of  the  pelvic-fascia,  and  in  one  it  was  due  to  disease 
of  the  ilium. 

In  making  a  differential  diagnosis  between  sacro-iliac  dis- 
ease and  chronic  ostitis  of  the  hip,  I  select  certain  points 
from  the  paper  to  which  I  am  already  much  indebted — cer- 
tain points  to  which  I  can  subscribe. 

i.  The  pain  from  sacro-iliac  disease  is  behind  the  hip- 


CHRONIC  ARTICULAR  OSTITIS  :  DIAGNOSIS.       301 

joint;  in  ostitis  of  the  hip  the  pain  is  usually  referred  to 
the  knee. 

2.  In  the  early  stage  of  sacro-iliac  disease  there  is  no  reflex 
spasm  of  any  of  the  groups  of  muscles  about  the  hip  when 
passive  motion  is  employed.     This  sign  is  well  known  in 
ostitis  of  the  hip. 

3.  In  sacro-iliac  disease  there  is  no  pain  on  pressure,  either 
below  Poupart's  ligment  or  behind  the  trochanter;  in  os- 
titis of  the  hip  there  is,  as  a  rule,  tenderness  in  one  or  both 
of  those  localities.   - 

4.  Pressure  on  the  ilium  at  right  angles  to  the  body  or  at- 
tempts to  rotate  this  bone,  always  causes  pain  in  sacro-iliac 
disease;  not  so  in  ostitis  of  the  hip. 

5.  In  sacro-iliac  disease  there  is,  as  a  rule,  tenderness  and 
periosteal  thickening  over  the  joint;  in  ostitis  of  the  hip 
tenderness  over  the  sacro-iliac  joint  is  seldom  present. 

6.  In  sacro-iliac  disease,  as  a  patient  stands,  the  body  is 
thrown  on  to  the  sound  side;  while  in  ostitis  of  the  hip  the 
body  inclines  to  the  diseased  side. 

7.  Greater  relief  is  experienced  from  absolute  rest  in  bed 
in  sacro-iliac  disease;  not  so  in  ostitis  of  the  hip. 

X.  VERTEBRAL  OSTITIS. 

It  was  a  long  time  before  I  could  believe  that  an  ostitis 
of  the  vertebrae  in  the  first  stage  could  give  signs  and  symp- 
toms that  would  lead  one  to  diagnosticate  an  ostitis  of  the 
hip  in  its  early  stage.  It  is  no  uncommon  thing  to  con- 
found a  caries  of  the  vertebrae  in  which  psoas  abscess  has 
formed  with  the  second  stage  of  a  coxo-femoral  os- 
titis. Some  unwelcome  facts,  however,  have  forced  them- 
selves upon  me,  and  I  feel  that  I  shall  not  make  the  diag- 
nosis of  chronic  ostitis  of  the  hip  in  its  early  stage  complete 
without  a  differentiation  from  vertebral  ostitis. 

I  saw  in  the  spring  of  1879  a  girl  aged  eight  years  who 
favored  the  left  side  in  walking.  The  limp  did  not  seem 
like  a  hip-limp,  and  yet  I  was  unable  to  classify  it.  I  tested 
the  joint  functions,  and  found  them  perfect  in  every  re- 
spect. There  was  no  shortening  and  no  atrophy,  and,  in- 
deed, no  pain.  She  simply  walked  lame,  and  the  lameness 
had  come  on  very  insidiously  six  weeks  before  I  saw  the 
case.  The  mother  was  a  typical  rheumatic.  A  hip  splint 
had  already  been  advised  by  a  specialist.  I  could  not  make 
a  diagnosis,  though  I  leaned  toward  rheumatism.  Nearly 

Lc  i 


302  DISEASES   OF  THE   HIP. 

two  weeks  elapsed,  and  I  examined  the  case  again  without 
finding  any  bone  or  joint  lesion.  Two  days  after  the 
last  visit  the  lameness  was  gone,  and  now  it  had  just 
returned,  and  with  it  a  little  pain  in  the  front  of  the  thigh. 

This  pain  soon  disappeared  under  the  sodium  salicylate, 
but  I  found  a  decided  halt  in  her  gait  nearly  three  months 
later.  It  was  a  paretic  limp,  and  there  was  a  half-inch 
atrophy  of  the  calf.  After  much  walking  she  referred  the 
pain  thereby  induced  to  the  posterior  aspect  of  the  thigh. 
I  fancied,  from  a  history  of  periodicity  obtained,  that  there 
might  be  a  malarial  element  in  the  case,  and  ordered 
quinine,  but  at  the  next  visit,  a  week  later,  the  pain  was  con- 
stant by  day  but  entirely  absent  by  night.  The  anterior 
crural  branches  were  seemingly  implicated.  At  this  visit  I 
found  for  the  first  time  resistance  and  pain  to  flexion  be- 
yond 90°.  I  was  puzzled  more  now  than  ever. 

A  couple  of  months  passed  and  I  found  a  limp  decidedly 
paretic.  She  threw  her  shoulders  back  unusually  far,  and 
there  was  an  inclination  also  to  the  left.  The  resistance  to 
flexion  was  not  present,  but  adduction  carried  toward  the 
extreme  limit  caused  pain.  ,  There  was  a  half-inch  atrophy 
of  the  thigh  and  a  marked  loss  of  power.  It  was  a  fact,  too, 
that  she  was  lamer  and  stiffer  after  sitting  awhile,  or  on  rising 
from  bed  in  the  morning.  On  general  principles  iodide  of 
potassium  was  prescribed,  and  in  a  week  or  two  she  was 
much  better.  Then,  again,  the  next  month  she  walked  as 
if  there  were  some  defect  in  the  lumbar  muscles,  and  I 
examined  the  spine  very  carefully  with  negative  result. 
The  column  was  flexible  and  normal  in  shape.  A  spinal 
brace,  however,  was  ordered  by  way  of  precaution.  A  few 
weeks  afterward  I  found  an  inch  atrophy  of  the  thigh,  and 
the  movements  at  hip-joint  absolutely  perfect.  Symptoms 
had  varied  as  the  weather  changed.  At  times  there  was  no 
sign,  no  symptom  of  any  kind.  I  lost  track  of  the  case 
early  in  1880,  and  did  not  see  it  again  until  I  traced  it  out 
in  March,  1883,  and  then  I  found  a  well-marked  kyphosis 
in  the  mid-dorsal  region  of  three  quarters  of  an  inch  on  a 
chord  of  six  inches.  The  deformity  had  come  on  very 
stealthily,  and  the  exacerbations  had  been  so  insignificant 
that  the  parents  thought  nothing  further  of  seeking  any  re- 
lief. The  hip  and  thigh  symptoms  had  long  since  disap- 
peared. Ankylosis  of  the  diseased  vertebrae  seemed  to  be 
pretty  well  established,  so  that  I  did  not  consider  a  brace 
necessary. 


CHRONIC  ARTICULAR  OSTITIS :   DIAGNOSIS.       303 

It  was  certainly  a  peculiar  case,  and  the  early  neuroses 
are  readily  explainable  now  on  the  theory  of  nerve-irritation 
at  the  foramina  of  exit.  That  her  symptoms  and  signs,  too, 
should  all  be  referred  to  the  extremities,  though,  is  certainly 
very  strange. 

While  on  a  visit  in  one  of  the  Western  States  late  in  the 
spring  of  1879,  I  was  asked  by  a  medical  friend  to  see  a 
case  in  which  no  clear  diagnosis  had  been  reached.  I 
naturally  felt  anxious  to  examine  the  patient  because  of  the 
obscurity  attached  to  the  case,  and  I  found  a  fairly  nourished 
female  child,  aged  four  years,  with  an  excellent  paternal 
family  history,  but  a  rheumatic,  maternal  history.  One 
day  in  October,  1877,  the  child  was  exposed  to  a  severe 
wetting,  and  complained  the  next  day  of  pains  about  the 
hips.  She  also  walked  awkwardly  at  that  time.  The 
pain  soon  subsided  without  disturbing  the  sleep,  and  the 
lameness  passed  away  within  a  week  without  treatment. 

It  was  observed  by  the  family  that,  for  three  or  four 
months  thereafter,  whenever  the  weather  changed  the  child 
would  complain  of  pain  about  the  hips,  and  be  a  little  stiff 
in  her  gait.  All  these  signs  and  symptoms  had  disappeared 
by  the  spring  of  1878,  and  nothing  further  attracted  atten- 
tion until  October  of  that  year,  when,  without  apparent 
provocation,  the  old  symptoms  returned  with  increased 
severity.  The  left  limb  seemed  to  receive  the  full  force  of 
this  attack,  but  in  the  course  of  a  month  or  two  both  thighs 
became  strongly  adducted,  and  reflex  muscular  spasm 
would  be  very  annoying,  especially  during  sleep.  Ap- 
paratus was  employed  for  a  rheumatic  deformity.  Such 
was  the  history,  and  while  I  aimed  to  get  an  unbiassed 
history  I  am  convinced  now  that  I  was  prejudiced  in  favor  of 
rheumatism.  The  lameness  was  bilateral,  but  more  marked 
on  the  left  side.  The  spinal  column  was  normal  in  every 
respect,  and  I  omitted  no  test  in  my  examination. 

The  next  signs  were  plain  enough,  but  were  thought  to 
be  due  to  the  apparatus  the  child  had  been  wearing.  They 
were:  flattening  of  the  natis,  resistance  to  flexion  beyond 
135°;  rotation  could  be  made  only  over  a  very  small  arc; 
resistance  offered  when  hyperextension  was  attempted.  All 
this  was  true  of  the  left  side,  but  in  addition  to  the  apparatus 
theory  there  were  some  signs  on  the  right  side  which  com- 
plicated a  diagnosis  more  than  ever.  These  were  resist- 
ance to  flexion  beyond  90°,  and  rotation  limited  to  one  half 
the  normal  arc. 


304  DISEASES  OF  THE  HIP. 

There  was  no  tenderness  in  either  hip,  no  infiltration  or 
periosteal  thickening  about  either  trochanter,  and  no 
difference  in  the  size  or  the  length  of  the  limbs.  For  my 
diagnostic  points,  then,  I  had: 

1.  A  rheumatic  element  in  the  family  history. 

2.  As  clear  a  history  of  exposure  to  cold  water  about  the 
hips  as  one  could  possibly  get. 

3.  Exacerbations  extending  over  three  or  four  months, 
closely  connected  with  changes  in  the  weather. 

4.  A  complete  (?)  remission  of  all  signs  and  symptoms 
for  six  months. 

5.  A  recurrence  of  exacerbation  when  the  cold  weather 
approached. 

6.  Bilateral  lameness  and  other  bilateral  signs. 

7.  A  six  months'  constant  wearing  of  apparatus  that  ex- 
tended from  axillae  to  feet. 

8.  Absolutely  negative  results  on  seeking  for  spinal  signs. 
With  these  points  and  the  bias  already  mentioned,  I  made 

a  diagnosis,  with  proper  precautions,  however,  of  chronic 
rheumatic  arthritis,  and  advised  the  removal  of  the  appa- 
ratus and  employment  of  massage  and  passive  motion- 
The  precautions  I  took  in  stating  this  diagnosis,  and  in 
giving  the  advice  I  did,  were:  that  it  was  very  difficult  in 
such  a  case  to  come  to  a  definite  conclusion  at  a  single  ex- 
amination, that  the  family  physician  should  be  consulted 
on  the  slightest  recurrence  of  symptoms,  and  that  the  ap- 
paratus should  be  reapplied  on  any  increase  of  deformity. 

Six  or  eight  months  later  rumors  came  that  the  child 
had  Pott's  disease  of  the  spine,  and  abscesses ;  later  still, 
that  there  was  "  hip-disease"  also  complicating  the  case. 
I  began  to  seek  for  more  definite  information,  and  after 
much  correspondence,  lay  and  professional,  I  succeeded  at 
last  in  realizing  that  I  had  made  an  error.  I  found,  on 
examination,  over  three  years  after  my  first  observation,  a 
distinct  kyphos  in  the  lumbo-sacral  region,  with  cicatrices 
in  the  gluteal  region  and  a  moderate  deformity  of  the  left 
hip  from  chronic  articular  ostitis,  with  cicatrices  about  the 
thigh. 

I  am  prepared  now  to  state,  after  the  above  confessions, 
that  a  differential  diagnosis  between  the  early  stage  of  a 
vertebral  ostitis,  even  in  the  dorsal  region,  and  the  early 
stage  of  a  chronic  ostitis  of  the  hip,  is  at  times  exceedingly 
hard  to  make.  Few  men,  I  think,  are  willing  to  admit  that 
there  can  be  any  difficulty  where  the  dorsal  vertebrse  are 


CHRONIC  ARTICULAR  OSTITIS  :   DIAGNOSIS.       305 

involved,  and  I  myself  was  not  prepared  to  admit  the  diffi- 
culty until  the  above  two  cases  came  under  my  notice  so 
conspicuously.  In  a  conversation  with  Dr.  Schoeneman  of 
this  city,  recently,  I  learned  that  in  his  opinion,  the  early 
signs  sometimes  run  closely  together. 
As  a  resume,  briefly,  then,  we  have: 

1.  Lameness  depending  on  diminution  in  nerve  or  mus- 
cular power,  when  it  exists  in  connection  with  disease  of  the 
dorsal  vertebrae  ;  the  lameness  of  an  ostitis  of  the  hip  lacks 
these  elements,  and  is  too  well  known  to  require  further 
description.     In  disease  of  the  lumbar  vertebrae,  the  lame- 
ness, on  close  inspection,  will  be  seen  to  depend  on  con- 
traction of  the  psoas,  and  there  will  be  more  lordosis  than 
is  seen  in  the  lameness  of  an  early  ostitis  of  the  hip. 

2.  A  patient  with  vertebral  ostitis  can  stand  as  well  on 
the  lame  limb  as  on  the  other ;    not  so  in  coxo-femoral 
ostitis. 

3.  Reflex  muscular  spasm  is  never  excited  by  employing 
passive  motion  of  the  hip  in  which  lameness  is  present,  the 
result  of  vertebral  disease  ;  as  a  rule  this  sign  is  always 
present  in  articular  bone  disease. 

4.  It  is  the  rule  to  get  a  history  of  complete  remissions 
in  the  lameness  of  the  one,  the  exception  in  the  other. 

I  have  given  only  some  important  points  when  other  and 
more  valuable  signs  are  absent.  Very  fortunately,  we  are 
not  called  upon  for  such  close  discrimination;  for  disease 
of  the  vertebra?,  especially  in  childhood,  has  a  pretty  defi- 
nite clinical  history,  and  rarely  is  it  that  the  signs  point  to 
lesions  about  the  joints  of  the  lower  extremity. 

Concluding  this  part  of  my  chapter,  I  may  incidentally 
mention  that  an  exostosis  sometimes  exists  in  the  neigh- 
borhood of  the  hip-joint,  and  gives  rise  to  symptoms  as 
well  as  signs,  that  may  lead  one  into  error.  I  have  myself 
had  such  a  case  and  was  saved  from  error  by  finding  exos- 
toses  in  other  parts  of  the  body.  Once  in  a  long  while  I 
find  a  case  with  certain  suspicious  signs  in  connection  with 
the  hip,  that  disappear  promptly  on  the  administration  of 
quinine.  Dr.  John  James  Berry,  of  Norwalk,  Conn.,  writes 
me  that  he  has  had  a  case  in  a  child  four  years,  with  pain 
and  resistance  to  movements  at  the  hip.  He  used  a  cathar- 
tic, and  quinia  for  three  days,  when  the  recovery  was  com- 
plete. Then,  again,  I  have  seen  cases  with  signs  of  disease 
at  the  hip  in  which  all  signs  yielded  to  the  expulsion  of 
lumbricoids. 


306  DISEASES  OF  THEJIIP. 

PART  II. — THE  DIAGNOSIS  IN  THE  SECOND  STAGE. 

It  would  seem  presumptious  to  discuss  this  branch  of  my 
subject,  inasmuch  as  the  impression  prevails  that  any  one 
can  diagnosticate  an  ostitis  of  the  hip  when  the  first  stage 
is  passed.  To  the  orthopedist,  however,  it  is  very  common 
to  find  cases  wherein  it  is  aught  but  easy  to  distinguish  the 
deformity  of  an  ostitis  from  that  of  a  psoas  abscess,  an  iliac 
abscess,  a  perinephritis,  or  a  chronic  articular  rheumatism. 
Cases  with  the  second  stage  signs  make  a  decided  impres- 
sion on  the  medical  attendant,  especially  when  a  perfect 
cure  takes  place  while  some  method  of  treatment  is  being 
employed,  but  on  the  laity  the  impression  borders  on  the 
miraculous. 

I.  PERINEPHRITIS. 

During  the  past  six  years  I  have  reported  so  many  cases 
of  this  affection  that  I  am  at  no  loss  for  illustrations.  In 
the  month  of  May,  1877,  a  boy  aged  twelve  was  admitted  to 
the  hospital,  and  the  following  is  the  record  made  of  his 
case: 

With  the  exception  of  one  or  two  of  the  diseases  of  in- 
fancy he  had  always  been  in  good  health.  The  father  had 
been  a  drunkard,  and  had  died  phthisical;  a  paternal  aunt 
had  did  of  "hip-disease;"  the  mother  gave  a  rheumatic  his- 
tory. The  disease  for  which  the  boy  is  now  admitted  was 
first  manifest  six  weeks  before,  supposably  originating  in  a 
"  cold."  Loss  of  flesh  had  been  marked,  and  his  appear- 
ance to-day  is  indicative  of  much  recent  suffering.  Pulse 
116,  R.  28,  T.  ioif°.  He  stands  with  body  inclined  to 
the  right,  the  lower  extremity  of  this  side  slightly  flexed  at 
hip  and  knee.  The  spinal  column  deviates  to  the  same 
side,  though  there  is  no  tenderness  along  the  column,  no 
angular  curvature,  no  pain  on  per-  or  concussion;  the  natis 
is  broadened.  Lameness  is  marked,  and  very  like  to  that  of  a 
patient  with  "  hip  disease,"  second  stage.  The  thigh  can- 
not be  extended  beyond  an  angle  of  165°  without  pain,  but 
can  be  flexed  and  rotated  over  normal  arcs.  Measurements 
of  the  two  limbs  identical.  He  complains  of  pain  about  the 
knee.  In  the  left  lumbar  region  the  erector-spinal  muscle 
is  full  and  tense,  giving  quite  a  ridge-like  prominence;  yet 
there  is  no  pain  here,  or  in  the  right  ilio-costal  space;  two 
and  one  half  inches  from  the  spinous  processes  of  the  verte- 
brae there  is  marked  tenderness,  which  extends  to  the  right 
in  a  horizontal  plane  to  a  point  immediately  above  the  an- 


CHRONIC  ARTICULAR  OSTITIS  :  DIAGNOSIS.       307 

terior  superior  spinous  process,  where  the  tenderness  be- 
comes more  extensive  in  area.  This  area  is  triangular,  ex- 
tending along  Poupart's  ligament.  There  is  subintegumen- 
tary  induration  along  and  above  the  ligament,  with  extra 
heat  and  comparative  dulness.  Flexion  of  thigh  relieves 
pain.  There  is  and  has  been  no  intestinal  derangement. 
Suffice  it  to  say,  we  had  no  difficulty  in  diagnosticating  a 
perinephritis.  The  progress  of  the  case  differed  from  the 
usual  type.  Suppuration  came  on  in  due  time,  a  large 
abscess  being  opened  just  above  Poupart's  ligament. 

In  August  the  case  was  discharged  cured,  all  deformity 
and  lameness  having  disappeared. 

In  typical  cases  the  disease  generally  begins  with  a  rigor 
or  two,  febrile  exacerbations  more  or  less  severe  according 
to  the  acuteness  of  the  attack,  lancinating  pains  in  lum- 
bar region,  loss  of  appetite,  and  general  indisposition.  In 
fact,  the  invasion  does  not  differ  materially  from  that  of 
other  acute  inflammatory  lesions,  unless  perhaps  the  pain 
be  more  localized,  and  if  the  child  be  very  young  the  lo- 
cality of  the  pain  is  not  discovered.  Constipation,  I  believe, 
is  always  present.  Very  soon  we  have  preternatural  immo- 
bility of  the  spine,  a  stooping  forward  with  elevation  of  the 
shoulders.  After  a  week  or  ten  days,  spasm  of  psoas 
muscle  occurs,  and  the  gait  becomes  characteristic  of  that 
so  commonly  regarded  as  the  second  stage  of  hip-joint 
disease.  The  urine  is  of  high  specific  gravity,  and  is  loaded 
with  urates.  The  tumefaction  appears  and  the  pain  be- 
comes excruciating.  If  an  exit  be  given  to  the  pus  a  speedy 
recovery  follows;  if  this  be  delayed  and  the  contents  of  the 
sac  be  really  pus,  it  burrows  along  the  cellular  tissue,  pro- 
ducing an  immense  abscess,  a  spontaneous  opening  is 
effected,  and  the  convalescence  is  protracted.  If,  on  the 
other  hand,  the  inflammatory  process  has  not  resulted  in 
suppuration,  the  contents  are  most  likely  serum,  and  reso- 
lution is  effected. 

The  position  of  the  limb  is  more  that  of  pure  flexion, 
while  in  the  second  stage  there  is  generally  an  element  of 
outward  rotation  associated  with  the  flexion. 

From  Dr.  Sayre's  work  I  have  taken  the  accompanying 
"cuts,  which  represent  very  finely  a  typical  deformity  of  the 
second  stage  of  an  ostitis  of  the  hip.  Fig.  30  represents  the 
earlier  appearances,  while  Fig.  31  represents  the  more  ad- 
vanced. When  abscess  appears  during  this  stage  the  ap- 
pearances are  still  more  unlike  those  of  a  .perinephritis. 


308 


DISEASES   OF  THE  HIP. 


1.  In  a  perinephritis  the  characteristic  deformity  appears 
within  a  week  after  the  first  symptoms;  in  a  chronic  ostitis 
the  deformity  is  very  slow  of  development,  and  never  ap- 
pears within  the  first  week. 

2.  In  perinephritis  it  is  the  rule  to  find  a  history  of  an 
initial  chill  and  febrile  reaction;  in  a  chronic  ostitis  a  chill 
is  never  present  as  a  symptom. 

3.  In  the  one  the  tumefaction  is  found  in  the  ilio-costal 


FIG.  30. — THE  BEGINNING  OF  THE 
SECOND  STAGE. 


FIG.  31. — SECOND  STAGE  WELL 
ADVANCED. 


space,  or  iliac  fossa;  in  the  other  it  is  never  found  in  the 
ilio-costal  space,  seldom  in  the  iliac  fossa,  but  as  a  rule  in 
the  vicinity  of  the  trochanter  major. 

4.  In  the  one,  resistance  to  passive  motion  is  offered  only 
in  extension,  and  traction  on  the  limb  increases  the  pain; 
in  the  other,  all  movements  are  resisted,  especially  flexion 
and  rotation,  while  traction  relieves  pain. 

5.  In  the  one  there  is  never  any  joint  tenderness;  in  the 
other  joint  tenderness  is  the  rule. 


CHRONIC  ARTICULAR  OSTITIS  :  DIAGNOSIS.       309 

These  constitute  the  chief  points  in  differential  diagnosis; 
but  in  conclusion  I  must  insist  on  a  careful  examination, 
several  times  if  need  be,  a  history  obtained  without  bias,  an 
unalterable  conviction  that  chronic  ostitis  is  from  the  be- 
ginning a  chronic  disease,  and  a  slowly  progressing  disease; 
I  wish  to  insist,  I  say,  on  these,  as  points  absolutely  essen- 
tial in  making  diagnosis.  I  dislike  to  be  hypercritical,  but 
I  firmly  believe  that  ninety  per  cent — yea,  I  am  prepared  to 
assert  a  much  larger  per  cent,  than  ninety — of  the  cases  of 
ostitis  of  the  hip  reported  as  cured  without  lameness  or  de- 
formity, cured  completely,  are  not  and  never  have  been 
cases  of  ostitis. 

II.  PRIMARY  PERITYPHLITIS  AND  ILIAC  ABSCESS. 

Surgeons,  I  am  well  aware,  are  unaccustomed  to  look 
uponaperityphlitis  as  any  thing  but  a  lesion  secondary  to  a 
typhlitis.  They  call  an  inflammation  which  involves  the  cel- 
lular tissue  surrounding  the  vermiform  appendix  a  subfas- 
cial  or  iliaccellulitis.  Still  surgical  authorities  do  recognize 
a  primary  uncomplicated  perityphlitis,  and  I  have  seen  cases 
whose  clinical  histories  were  very  sharply  defined.  It  is 
immaterial,  however,  for  purposes  of  differential  diagnosis 
whether  the  cellulitis  be  on  the  right  or  the  left  side.  In 
either  event  the  signs  closely  resemble  those  of  the  second 
stage  of  a  chronic  articular  ostitis  of  the  hip. 

A  case  I  saw  in  September,  1878,  was  in  a  boy  aged  six 
years,  whose  history  was  as  follows: 

Absolutely  free  from  hereditary  diseases  or  the  cachexia 
which  often  follows  in  the  wake  of  infantile  disorders. 
True,  in  the  early  spring  of  1878  he  had  some  fever  which, 
to  use  the  mother's  expression,  made  him  "  deaf,  dumb,  and 
blind,"  yet  he  made  an  excellent  recovery  after  six  weeks, 
and  was  in  good  health  until  the  beginning  of  September 
(three  weeks  prior  to  the  day  he  presented  at  the  hospital), 
when  he  came  in  from  play  reporting  to  his  mother  that  he 
had  had  a  fall.  The  child's  sleep  was  disturbed  the  same 
night;  he  complained  of  general  soreness,  and  was  appa- 
rently quite  feverish.  No  contusions  could  be  found,  yet 
he  continued  from  that  time  forth  to  grow  more  lame  and 
to  sleep  more  uneasily;  in  fact  it  was  difficult  to  get  a  posi- 
tion in  bed  that  would  be  at  all  comfortable  for  any  length 
of  time.  While  quiet  the  little  patient  was  free  from  pain, 
but  any  movement  caused  him  to  cry  out  sharply.  He  has 


3IO  DISEASES   OF  THE  HIP. 

limped  from  the  very  beginning,  favoring  the  righ  limb; 
at  times  has  been  able  to  go  about  only  on  the  hands  and 
knees,  and  at  other  times  he  has  walked  comparatively 
erect.  It  was  not  ascertained  whether  the  patient  was  con- 
stipated during  this  period,  or  whether  he  had  vomited,  or 
whether  he  had  eaten  anything  that  would  be  likely  to 
lodge  in  the  appendix.  The  mother  insisted  only  on  his 
high  fever.  The  nurse  soon  discovered  that  he  was  obsti- 
nately constipated  some  days  after  admission. 

The  case  had  been  regarded  as  one  of  dislocation,  and  an 
attempt  had  been  made  at  reduction  under  ether.  This 
was  three  or  four  days  previous  to  admission  to  hospital, 
and  being  sent  to  one  of  our  consulting  surgeons,  he  could 
find  no  evidence  of  dislocation,  but  reported  it  as  one  of 
severe  strain  of  the  hip-joint  which  would  probably  eventu- 
ate in  disease  of  this  articulation. 

The  expectant  treatment  was  employed  in  the  hospital. 
It  was  recorded,  however,  that  the  boy  was  fairly  nour- 
ished, could  only  stand  when  assisted,  and  could  not  walk 
at  all;  that  the  right  thigh  was  flexed  on  the  pelvis  at  an 
angle  of  nearly  90°,  extreme  flexion  being  admissible  while 
extension  was  resisted  by  muscular  action;  that  there  was 
some  swelling  about  the  hip  and  thigh  obliterating  the 
fold;  and  that  further  examination  was  postponed,  so  ex- 
cessive was  the  tenderness.  His  vital  signs  were  not  even 
recorded,  but  on  the  26th,  five  days  after  admission,  the 
pulse  in  the  evening  was  120,  respiration  36,  temperature 
ioif°;  and 'at  the  same  time  next  day  the  record  stood  124, 
27>  I03f°-  From  this  date  until  Oct.  i6th  the  temperature 
ranged  between  101°  and  103!°  for  the  evening,  while  in 
the  morning  it  was  normal. 

Four  days  after  admission  it  was  observed  that  there  was 
marked  tenderness  in  the  inguinal  region,  with  well-defined 
induration  above  Poupart's  ligament,  that  all  the  move- 
ments at  the  hip,  save  extension,  could  be  made  with  care, 
and  that  the  boy  could  easily  bear  his  entire  weight  upon 
the  limb.  Joint  disease  was  readily  excluded,  and  the  le- 
sion, an  inflammatory  one,  definitely  located  in  the  iliac 
fossa. 

Within  a  fortnight  a  long,  oval-shaped,  fluctuating  tumor 
presented  above  Poupart's  ligament,  was  incised,  pus  evac- 
uated, and  in  another  fortnight  the  case  was  discharged 
cured. 

It  is  not  necessary  always  for  suppuration  to  have  taken 


CHRONIC  ARTICULAR  OSTITIS:  DIAGNOSIS.       31! 

place  in  order  that  a  diagnosis  may  be  made.  I  have  on 
my  case-books  several  in  which  no  suppuration  occurred. 
One  is  noted  in  detail,  and  I  shall  present  it  in  this  connec- 
tion in  order  that  the  points  in  differential  diagnosis  may 
be  the  better  illustrated. 

Early  in  the  last  week  of  October,  1879,  a  boy,  six  and  a 
half  years  of  age,  was  carried  into  the  waiting-room  of  the 
hospital,  and  so  tender  was  the  little  fellow  that  his  cloth- 
ing could  with  great  difficulty  be  removed  for  examination. 
He  was  in  perfect  health  and  sound  in  limb  three  weeks 
previously,  and,  with  the  exception  of  a  slight  attack  of 
malarial  fever  two  years  ago,  he  had  been  uninteruptedly 
healthy.  He  is  reported  to  have  had  a  fall, — no  one  saw  him 
fall, — to  which  his  parents  attributed  the  present  lameness. 
His  first  symptom  was  pain  about  the  right  hip,  the  night 
of  the  day  on  which  he  reported  his  fall;  next  day  he  could 
scarcely  walk,  and  four  or  five  days  later  medical  advice 
was  sought,  the  surgeon  (one  in  very  good  standing)  pro- 
nouncing it  "hip  disease"  (so  the  father  stated)  and  apply- 
ing a  weight  and  pulley,  which  had  been  employed 
constantly  until  the  twenty-sixth,  the  day  before  this  visit 
to  the  hospital.  During  this  whole  period  the  patient  suf- 
fered much  pain  in  the  knee  and  groin,  requiring  anodynes 
one  or  two  nights.  The  condition  of  his  bowels  during  the 
first  week  could  not  be  ascertained.  His  rectal  tempera- 
ture on  this  date  was  ioif°.  The  family  history  was  nega- 
tive on  father's  side,  neurotic  on  mother's,  i.e.,  she  was 
insane.  The  boy  was  greatly  emaciated,  and  tongue  was 
Boated.  He  was  able  to  stand  if  assisted,  bearing  his  entire 
weight  on  the  left  limb  with  the  right  semiflexed  at  hip  and 
knee  and  rotated  inward,  yet  he  could  not  walk. 

While  sitting  on  the  side  of  the  bed  he  voluntarily  crosses 
the  right  leg  over  the  left  knee,  and  as  he  lies  down  there  is 
nothing  to  be  seen  abnormal  save  a  lateral  deviation  of  the 
spinal  column  in  the  lumbar  region  to  the  left. 

In  the  dorsal  decubitus  he  voluntarily  flexes  the  thigh  on 
the  pelvis  completely,  can  abduct  and  adduct,  but  cannot 
extend  beyond  90°  without  pain,  and  if  passive  extension 
be  attempted,  the  boy  resists,  crying  aloud.  Rotation  can 
be  easily  made,  if  made  with  care.  Nothing  can  be  felt  per 
rectum  save  a  few  scybalae.  Pressure  over  the  trochanter 
in  the  line  of  the  neck  gives  no  pain,  nor  does  concussion 
of  hip.  No  infiltration  about  the  trochanter  or  below  Pou- 
part's  ligament.  A  cicatrix  of  recent  vesication  is  seen  over 


312  DISEASES  OF  THE  HIP. 

the  gluteal  region.  The  abdominal  walls  are  a  little  re- 
tracted, and  there  is  neither  tenderness  nor  infiltration  in 
either  ilio-costal  space,  nor  is  there  any  in  the  left  iliac 
fossa,  but  in  the  right  tumefaction  can  be  felt  distinctly 
within  a  triangular  area  bounded  above  by  a  line  extend- 
ing from  the  top  of  the  crest  of  the  ilium  to  the  median 
line  just  below  the  navel,  laterally  by  the  median  line  and 
below  by  Poupart's  ligament.  There  is  dulness  here  and 
excessive  tenderness,  but  no  fluctuation,  and  no  tumor 
present  to  the  eye. 

The  result  was  a  resolution  of  the  mass  under  blistering 
and  hot  fomentations.  He  was  well  in  a  couple  of  months, 
and  the  diagnosis  was  fully  confirmed. 

From  the  foregoing  histories  and  remarks  the  recognition 
of  a  case  of  iliac  abscess  should  depend  on  a  reasonably 
careful  examination.  To  distinguish  this  from  an  ostitis 
of  the  hip  in  the  second  stage,  one  should  remember  that — 

1.  The  deformity   is  of   too   rapid    development   for  a 
chronic  ostitis. 

2.  The  constitutional  symptoms  are  too  prominent. 

3.  That  resistance  to  extension  alone  never  occurs  in  the 
second  sl.age  of  the  disease. 

4.  That  tumefaction  in  the  iliac  fossa  alone  rarely  occurs. 

III.  THE  SUPPURATIVE  STAGE  OF  CARIES  OF  THE  DORSAL 
AND  LUMBAR  VERTEBRA. 

The  natural  delays  in  the  appearance  of  abscess  from 
caries  of  the  vertebrae  make  one  peculiarly  liable  to  asso- 
ciate them  with  the  hip  or  thigh.  I  have  seen  most  excel- 
lent surgeons  call  a  tumor  in  the  gluteal  region,  for  in- 
stance, a  bursitis  or  a  hip  abscess,  when  a  deformity  of  the 
lower  dorsal  or  lumbar  vertebrae  was  present,  but  regarded 
as  perfectly  innocuous  and  unconnected  with  the  aforesaid 
tumor.  Again,  old  fistulous  openings  on  the  hip  or  the 
thigh,  with  deformity  of  the  limb,  are  time  and  again 
looked  upon  as  associated  with  the  nearest  joint,  and  on 
being  explored  lead  to  diseased  vertebrae.  If  one  will  look 
upon  a  caries  sicca  as  an  exceedingly  rare  lesion,  and  learn 
that  an  abscess  from  bone  disease  may  appear  at  any  time 
during  a  natural  lifetime,  many  errors  will  be  avoided. 
It  is  especially  true  of  vertebral  caries  that  a  residual  ab- 
scess will  take  one  of  several  courses,  and  appear  in  the 
most  unlooked-for  localities.  A  very  common  site  is 


CHRONIC  ARTICULAR  OSTITIS :   DIAGNOSIS.       313 

Scarpa's  space;  and  another  site  nearly  as  common  is  the 
outer  and  posterior  aspects  of  the  thigh.  Cases  like  the 
following  come  frequently  under  my  observation. 

In  the  early  part  of  January,  1878,  a  mother  called  to  re- 
port her  child,  an  out-patient  of  the  hospital,  as  unable  to 
attend,  so  helpless  had  he  become  by  reason  of  the  progress 
of  the  disease.  She  mentioned  the  name  of  her  family  phy- 
sician, whom  I  knew  to  be  thoroughly  competent,  from  his 
surgical  experience  in  some  of  the  best  hospitals  in  the  city, 
to  take  charge  of  any  case,  and  to  him  I  referred  this  pa- 
tient, a  boy,  aged  eleven  years,  under  our  treatment  since 
March,  1874,  for  caries  of  the  lower  dorsal.  When  I  last 
saw  the  boy  in  August,  1877,  there  was  a  circumscribed 
tumor  over  the  left  hip,  and  I  recognized  this  as  a  spinal 
abscess,  ordering  appropriate  treatment  therefor.  I  in- 
structed the  mother  to  ask  the  physician  to  whom  I  had 
just  referred  the  case  to  notify  me  as  to  present  condition. 

I  was  informed  by  letter  the  seventeenth  of  January,  that 
the  child  with  caries  of  the  spine  had  also  hip-joint  disease 
of  over  a  year's  standing,  received  from  a  fall;  that  the  leg 
was  flexed  somewhat  upon  the  thigh,  and  the  thigh  upon 
the  abdomen,  the  usual  position  of  the  limb.  I  immediately 
requested  a  consultation,  but  the  doctor  was  called  out  of 
town,  and  left  word  for  me  to  examine  at  my  convenience. 

A  few  days  later  I  made  a  careful  examination,  and  found 
a  marked  angular  deformity  of  the  spine,  a  soft,  fluctuating 
tumor  over  upper  and  outer  aspect  of  thigh,  measuring 
three  inches  vertically,  and  an  inch  and  a  half  transversely. 
The  circumference  of  the  limb  at  every  point  save  over  this 
tumor  was  identical  with  that  of  the  other  limb ;  there 
was  no  shortening  whatever,  and  the  thigh  could  be  moved 
in  every  direction  without  any  pain  in  the  hip  or  at  the 
knee ;  but  when  complete  extension  was  made,  the  skin 
covering  the  tumor  was  put  on  stretch,  and  the  boy  com- 
plained of  pain  here.  Rotation  was  easily  accomplished, 
and  I  could  find  no  disease  at  the  hip  by  any  of  the  recog- 
nized signs.  In  the  absence  of  shortening,  atrophy,  and 
muscular  contractions  about  the  hip  limiting  motion,  and 
in  view  of  the  position  of  the  limb,  I  could  not  make  out 
any  hip-joint  disease,  and  so  reported  to  my  friend  the 
physician. 

Two  years  ago  a  case  in  a  boy  aged  five  was  examined 
by  a  member  of  our  staff,  and  pronounced  to  be  lumbar 
caries  with  psoas  abscess.  The  normal  curve  was  lost,  and 


314  DISEASES   OF  THE   HIP. 

the  spine  in  this  region  was  suspiciously  stiff.  The  right 
limb  was  nearly  in  the  position  of  the  second  stage.  On 
palpation  an  elastic  tumor  could  be  recognized  in  the  iliac 
fossa.  Treatment  for  the  spinal  caries  was  promptly  begun, 
and  in  the  course  of  three  months  the  case  presented  at 
another  hospital,  where,  after  a  long  examination,  it  was 
pronounced  "  hip-disease,"  and,  with  a  look  that  combined 
egotism  and  pity,  the  diagnostician  told  the  father  that  the 
spinal  brace  was  of  no  service  to  the  boy. 

When  I  saw  the  patient  a  month  afterward  there  was  a 
distinct  kyphos  in  lumbar  region,  a  well-marked  tumor  in 
iliac  region,  and  resistance  only  to  extension  of  the  limb. 

Such  cases  are  not  rare,  and  I  could  illustrate  at  great 
length  did  it  seem  necessary.  I  shall  content  myself  with 
recounting  some  of  the  more  important  points  in  the  differ- 
ential diagnosis  : 

1.  In  residual  abscess  about  the  hip  there  will  be  either 
a  history  of  spinal  symptoms  or  the  presence  of  the  de- 
formity, if  the  abscess  come  from  diseased  vertebrae. 

In  the  second  stage  of  a  chronic  ostitis  at  the  hip,  spinal 
symptoms  and  signs  are  wanting. 

2.  In  a  spinal  caries  with  deformity  at  the  hip,  the  resist- 
ance on  passive  movements  of  the  thigh  will  be  confined 
to  the  muscles  in  or  about  which  the  infiltration  is  mani- 
fest. 

In  the  second  stage  of  a  chronic  articular  ostitis  the  re- 
sistance, as  a  rule,  is  in  all  the  periarticular  muscles  and  the 
hip  is  often  locked  against  any  movement.  In  other  words, 
the  resistance  in  the  one  is  from  mechanical  causes,  in  the 
other  it  is  reflex. 

3.  In  the  one  there  is  no  tenderness  at  the  hip-joint  and 
the  patient  can  easily  bear  all  the  weight  on  the  limb;  in 
the  other,  joint  tenderness  is  usually  present,  and  if  not  de- 
tected by  manual  examination,  becomes  quite  apparentjwhen 
the  patient  makes  an  effort  to  stand  alone  on  the  limb. 

4.  The  coexistence  of  a  kyphos  in  lower  dorsal  or  lum- 
bar regions  with  open  sinuses  about  the  upper  third  of  the 
thigh,  in  a  thigh  either   parallel  with  its  fellow  or  at  an 
angle  of  flexion,  furnishes  presumptive  evidence  against  a 
secon  .'  stage  of  chronic  ostitis  of  the  hip. 

5.  Fi   ally,  a  well-conducted  physical  examination,  aided 
by  the  us  ^  of  the  probe,  will  enable  one  to  differentiate  in 
cases,  however  doubtful  they  may  be. 

I  have  nev  ?r  been  able  to  satisfy  myself  of  the  existence 


CHRONIC  ARTICULAR  OSTITIS  :  DIAGNOSIS.       315 

of  a  primary  psoitis,  and  hence  have  not  included  this  affec- 
tion among  the  lesions  from  which  a  chronic  bone  lesion  of 
the  hip  in  its  second  stage  is  to  be  differentiated.  Admit- 
ting, however,  the  propriety  of  recognizing  such  a  lesion, 
we  should  have  the  same  points  in  differential  diagnosis  as 
have  been  enumerated  in  the  foregoing  diseases. 

IV.  ACUTE   EPIPHYSITIS. 

Inasmuch  as  our  observations  in  acute  epiphysitis  are 
generally  first  made  after  the  initial  lesions  have^been  fully 
established,  we  rfaturally  find  the  limb  in  a  position  that 
looks  very  much  like  that  of  a  second  stage  of  a  chronic 
epiphysitis.  Since  I  prepared  my  chapter  on  this  acute 
articular  disease  of  infancy,  I  have  found  a  very  instructive 
series  of  cases  reported  by  Mr.  Thomas  Smith,  in  the  Saint 
Bartholomew  Hospital  Reports  for  1874.  Mr.  Smith  writes 
his  clinical  paper  on  "  The  Acute  Arthritis  of  Infants,"  and 
my  attention  was  called  to  it  by  reading  a  report  of  some 
similar  cases  by  Mr.  Morrant  Baker  in  the  British  Medical 
Journal  for  September  i,  1883.  His  paper  was  presented 
at  the  last  meeting  of  the  British  Medical  Association,  and 
is  entitled  "  Epiphysal  Necrosis  and  its  Consequences." 

I  very  much  regret  that  I  did  not  see  Mr.  Smith's  contri- 
bution earlier,  for  I  should  then  have  had  a  clearer  idea  of 
my  own  cases.  Even  in  this  connection  I  take  pleasure  in 
quoting  from  Mr.  Smith  the  following  paragraph,  which 
will  lay  a  most  excellent  basis  for  differential  diagnosis. 
He  says  :  "  It  occurs,  so  far  as  my  own  experience  extends, 
within  the  first  year  of  life,  and  is  characterized  by  the  sud- 
denness of  its  onset  and  the  rapidity  of  its  progress  and 
termination,  whether  the  latter  be  of  a  fatal  or  favorable 
kind.  It  is  very  dangerous  to  life,  and  intensely  destruc- 
tive to  the  articular  ends  of  the  bones,  which,  of  course,  at 
this  period  of  life  are  largely  cartilaginous.  Lastly,  I  would 
mention  as  a  feature  of  the  disease,  that  it  rarely  produces 
anchylosis,  but  leaves  a  child  with  a  limb  shortened,  by  loss 
of  part  of  the  articular  end  of  some  bone,  and  with  a  weak- 
ened, flail-like  joint." 

Mr.  Baker  believes  as  I  do,  that  the  cases  Mr.  Smith  has 
described  had  the  epiphysis  as  probably  the  primary  seat  of 
disease.  Indeed  Mr.  Smith  stated  himself  that  it  seemed 
"that  in  many  cases  the  formation  of  a  subarticular  ab- 
scess  in  the  bone  must  have  been  the  first  step  in  the  joint 


3l6  DISEASES  OF  THE  HIP. 

affection."  Along  with  Mr.  Baker  and  Mr.  Macnamara,  I 
believe  that  the  disease  is  not  exclusively  confined  to  the 
first  year  of  life.  I  have  not  had  the  experience  Mr.  Smith 
had  in  the  mortality  of  such  cases,  and  was  not  aware  until 
I  had  read  his  reports  that  there  was  such  destruction  to 
life.  However,  I  am  digressing,  and  shall  revert  to  the 
object  for  which  I  introduced  this  discussion,  viz.,  differ- 
ential diagnosis. 

1.  Acute  epiphysitis  occurs  at  a  much  earlier  period  of 
life  than  does  chronic  articular  ostitis. 

2.  The  progress  of  the  disease  is  much  more  rapid  and 
the  symptoms  and  signs  are  much  more  pronounced.     One 
is  an  acute  process,  the  other  a  chronic  process. 

3.  The  infiltration  in  the  one  is  more  of  a  phlegmonous 
nature,  while  that  in  the  other  presents  the  features  of  a 
cold  abscess. 

4.  The  joint  movements  in  the  one,  despite  the  infiltra- 
tion, are  less  restricted  than  those  in  the  other. 

Monafticular  rheumatism  presents  many  of  the  features 
of  the  second  stage  of  a  chronic  ostitis  of  the  hip.  The 
signs  are  so  similar  that  one  must  rely  on  the  history  and 
the  existence  of  rheumatic  signs  in  other  organs. 

PART  III. — THE  DIAGNOSIS  IN  THE  THIRD  STAGE. 

In  this  stage  the  signs  are  so  well  marked  and  so  charac- 
teristic that  the  probabilities  of  error  are  reduced,  it  would 
seem,  to  a  minimum.  Yet  in  my  experience  there  are 
several  lesions  which  give  deformities  similar  to  the  one 
under  consideration. 

It  must  be  remembered  that  real  shortening  is  always 
present,  that  deformity  is  always  present,  and  that,  as  a 
rule,  sinuses  and  ulcers  are  present.  The  favorite  position 
of  the  limb,  it  will  also  be  remembered,  is  in  flexion,  adduc- 
tion, and  rotation  inward.  By  reason  of  the  varieties  in 
position,  it  often  happens  that  a  unilateral  congenital  dis- 
location is  diagnosticated  as  the  third  stage  of  a  chronic 
ostitis  of  the  hip.  It  is  frequently  reported  that  a  child  has 
become  suddenly  lame,  when  on  investigation  it  will  be 
learned  that  the  lameness  has  always  existed.  If  no  history 
be  obtainable,  then  the  diagnosis  is  often  obscure.  I  do 
not  see,  however,  how  any  one  can  fail  to  diagnosticate  a 
congenital  dislocation  if  an  average  amount  of  care  be  taken 
in  the  examination. 


CHRONIC  ARTICULAR  OSTITIS :    PATHOLOGY.      317 

The  limb  is  parallel  with  its  fellow;  is  rotated  outward 
over  a  small  arc;  is  shorter,  but  can  be  made  equal  with 
its  fellow  by  traction;  has  no  abscess  or  previous  signs  of 
suppuration ;  this  freedom  of  motion,  and  above  all  the  ovoid, 
or,  globular  tumor  beneath  the  gluteal  group  of  muscles,  is 
very  characteristic.  All  these  signs,  even  without  a  history, 
are  sufficient  to  exclude  a  chronic  ostitis. 

From  a  traumatic  dislocation  the  diagnosis  is  not  always 
easy  of  differentiation.  I  saw — October,  1880 — a  boy  eight 
years  of  age,  whose  mother  gave  me  the  following  history: 
Three  and  a  half  months  before — June  3oth — he  was  on  his 
way  from  school  as  active  a  boy  as  there  was  in  the  neigh- 
borhood, and  one  as  free  from  lameness,  when  he  passed  a 
house  in  process  of  erection.  As  he  passed  a  beam  fell 
across  his  back  and  thigh,  pinning  him  to  the  sidewalk. 
He  was  carried  home,  and  the  limb  was  treated  for  a  frac- 
ture of  the  thigh.  In  two  weeks  he  was  out  of  bed  and 
going  about  on  crutches.  He  had  been  lame  ever  since  the 
accident.  The  history  was  very  clearly  given,  and  without 
any  suggestions.  I  found  the  limb  adducted  and  rotated 
inward  over  a  small  arc;  two  inches  shortening,  both  as 
measured  from  the  anterior  spinous  process  and  the  um- 
bilicus; the  trochanter  very  prominent,  and  a  rounded  glob- 
ular body  beneath  the  gluteal  muscles,  moving  under  my 
finger  as  I  rotated  the  limb.  There  was  no  infiltration 
about  the  hip,  but  on  the  anterior  surface  of  the  thigh,  at 
its  middle  third,  was  an  irregular  bony  mass,  about  the 
size  of  a  split  walnut,  hugging  the  former  closely,  and  tender 
on  handling.  The  movements  at  the  hip  were  good  in  all 
directions  save  in  abduction.  I  made  out  a  dislocation  on 
the  dorsum,  with  possibly  an  old  fracture  of  the  thigh,  and 
had  my  diagnosis  confirmed  by  one  eminent  in  this  branch 
of  surgery.  On  account  of  the  bony  tenderness  about  the 
callus,  it  was  deemed  inadvisable  to  make  any  attempts  at 
reduction  at  that  time. 

A  few  weeks  later  two  of  my  assistants  recognized  the 
same  patient  at  an  orthopedic  clinic,  furnishing  a  text  for 
a  lecture  on  "hip-disease"  in  its  third  stage.  The  tension 
of  the  adductors  was  referred  to  as  being  specially  diag- 
nostic. 

I  confess  that  I  was  greatly  surprised,  and  wondered  how 
I  could  have  come  so  wide  of  the  mark,  especially  as  I  had 
examined  the  case  so  carefully,  recording  every  step  in  the 
process.  I  have  sought  the  boy  in  vain  during  the  past  few 


318  DISEASES  OF  THE  HIP. 

months,  and  hence  am  unable  to  give  the  final  conclusion. 
The  case,  however,  is  interesting  from  the  fact  that  two 
specialists  differed  so  widely  on  points  that  should  have 
been  perfectly  clear.  There  is  one  point  on  which  I  may 
have  failed,  viz.,  the  early  history.  The  clinical  lecturer 
seems  to  have  learned  that  the  boy  was  lame  prior  to  the 
accident.  The  mother  to  me  asseverated  that  he  was  not 
lame  prior  to  the  accident. 

Caries  of  the  pelvic  bones,  with  much  infiltration  and 
ulceration  of  the  soft  parts,  is  sometimes  mistaken  for  ar- 
ticular ostitis.  I  have  notes  of  more  than  one  case  where 
such  a  diagnosis  was  made  by  very  competent  observers. 

The  deformities  of  rheumatism  are  often  regarded  as 
those  of  the  third  stage  of  disease  at  the  hip.  Last  summer 
a  case  was  sent  me  from  a  suburban  town  by  the  local  phy- 
sician, who  wrote  me  that  the  patient  had  had  a  rheumatic 
inflammation  resulting  in  deformity  of  the  hip.  Not  caring 
particularly  for  the  deformities  of  this  disease  in  the  adult, 
I  accepted  the  case  with  some  hesitation.  In  fact,  when 
first  written  to  about  the  case  I  referred  the  doctor  to  an- 
other hospital.  Finally,  the  patient  and  a  medical  friend 
called  to  see  me,  asking  at  least  for  my  diagnosis.  My 
first  impression,  on  looking  at  the  patient,  a  man  aged 
twenty-four  years,  was  that  I  had  here  an  old  deformity 
from  chronic  articular  ostitis  of  the  hip.  He  was 
pale,  cachectic-looking,  and  had  a  marked  deformity 
of  the  right  hip,  the  limb  being  in  flexion  at  an  angle  of 
about  160°  in  inward  rotation  over  a  quadrant,  and  the 
foot  touching  the  floor  only  by  toes  and  ball.  The  rotation 
I  desire  to  emphasize  by  stating,  furthermore,  was  so  great 
that  the  outer  side  of  the  knee  rested  against  the  popliteal 
space  of  the  left  side.  There  was  an  inch  atrophy  of  the 
thigh,  and  the  limb  presented  a  practical  shortening  of  two 
inches,  though  there  was  no  real  shortening. 

The  trochanter  was  not  above  Nelaton's  line,  but  was  an 
inch  and  a  quarter  nearer  the  anterior  superior  process  than 
was  its  fellow. 

I  looked  for  cicatrices  and  could  not  find  any,  nor  could  I 
find  any  infiltration.  The  joint  was  absolutely  immovable. 
It  then  occurred  to  me  that  I  had  better  get  a  history,  and 
I  learned  that  he  was  perfectly  well  and  free  from  lameness 
on  the  22d  of  February,  when  he  "caught  cold;"  that  he 
overheated  himself  the  next  day  running  for  a  train;  next 
was  sore  in  "all  his  body  and  limbs."  The  same 


CHRONIC  ARTICULAR  OSTITIS :    PATHOLOGY.      319 

evening  he  was  decidedly  feverish,  and  did  not  leave  his  bed 
the  next  day.  The  symptoms  fixed  themselves  in  the  right 
hip,  and  he  lay  a  sufferer  for  nine  weeks,  the  limb  assuming 
a  position  of  flexion  and  adduction.  I  had  no  difficulty 
after  so  clear  a  history  of  diagnosticating  a  rheumatic 
periarthritis,  and  advised  brisment  force  under  ether. 

He  entered  St.  Luke's  Hospital,  and  Dr.  Bull,  confirming 
my  diagnosis,  carried  out  the  treatment  I  had  recommended. 
The  result  was  all  that  we  could  desire;  and  at  present 
writing  the  patient  has  a  very  useful  limb,  with  a  very  fair 
amount  of  motion. 

In  closing  this  chapter  I  can  do  no  better  than  insist  on 
the  value  of  an  early  diagnosis  in  the  first  stage.  The  signs 
are  clear  enough,  as  a  rule,  when  taken  in  connection  with 
the  history.  Exceptional  difficulties  in  diagnosis  have  been 
enumerated,  and  repetition  is  unnecessary. 


CHAPTER  XV. 

THE  TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS — GEN- 
ERAL CONSIDERATIONS. 

The  treatment  best  adapted  to  primary  bony  lesion  of 
the  hip  is  one  of  the  most  difficult  problems  in  the  whole 
range  of  surgery.  Men  may  talk  and  men  may  write,  yet 
the  bony  lesions  of  the  hip,  as  a  rule,  advance  to  destruc- 
tive changes.  There  are  many  and  varied  forms  of  appa- 
ratus in  use,  and  nearly  all  aim  to  meet  the  same  indication 
for  treatment.  All  aim  to  secure  rest  to  the  articular  sur- 
faces. 

The  therapeutics  of  chronic  articular  ostitis  of  the  hip 
resolves  itself  into  the  following  divisions: 

1.  The  constitutional  with  the  expectan^  for  the  early 
stages. 

2.  The  expectant. 

3.  The  mechanical. 

a.  Pure  fixation. 

b.  Extension  with  and  without  motion. 

4.  Operative. 

While  I  have  employed  these  divisions,  I  fully  recogYiize 
the  fact  that  hard  and  fast  lines  cannot  be  drawn;  for 
nearly  all  surgeons  recognize  some  hereditary  vice  as  the 
predisposing  cause,  and  hence  see  an  indication  for  some 
internal  medication.  There  are  a  few,  however,  who  discard 
all  mechanical  appliances,  especially  in  the  first  and  second 
stages,  adhering  strictly  to  a  constitutional  treatment 
throughout.  These,  however,  rely  on  topical  treatment  as 
well,  and  aim  to  relieve  symptoms  by  the  application  of  mild\ 
counter-irritants  and  of  vesicants.  This  cannot  be  called 
the  expectant  plan  of  treatment,  for  it  is  only  in  the  early 
stages  that  any  effort  is  made  to  relieve  symptoms.  The 
deformity  that  arises  seldom  receives  any  attention,  and 
certainly  no  mechanical  efforts  are  made  to  prevent  deform- 
ity. In  diseases  of  the  ankle,  or  the  knee,  or  the  spine, 
appliances  are  employed  to  prevent  deformity;  not  so  in 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   321 

diseases  of  the  hip.  There  is  a  certain  angle  of  deformity 
that  is  best  for  an  ankylosed  knee,  and  perhaps  it  may  be 
considered  that  the  angle  at  which  the  disease  leaves  the 
hip  is  generally  better  than  we  can  bring  about  by  any 
treatment.  This  is  the  explanation  I  have  adopted  for  the 
non-interfering  method,  and  before  proceeding  further  it 
would  be  well  to  define  my  terms. 

What  do  we  understand  by  the  term  expectant  ?  Liter- 
ally it  means  to  wait.  Waiting  for  symptoms  and  signs  to 
arise  before  treatment  is  instituted,  and  thus  directing  the 
treatment  to  these  phenomena  of  disease;  discontinuing  as 
they  disappear  or  are  modified;  resuming  on  their  reappear- 
ance— this  is  what  is  generally  understood  as  expectant 
treatment.  Physicians  who  adhere  to  the  expectant  treat- 
ment are  known  as  conservatives;  indeed,  expectancy  and 
conservatism  have  somehow  become  synonymous  terms.  If 
one  treats  a  case  expectantly  then  he  is  called  upon  to  re- 
lieve the  symptoms  during  the  exacerbation  in  any  way 
that  he  may  find  the  most  satisfactory.  For  instance,  if  he 
finds  that  rest  in  bed  with  weight  and  pulley  gives  relief 
the  more  promptly,  he  will  employ  this  method;  if  he  finds 
that  local  applications,  such  as  cold-water  dressings,  hot 
fomentations,  mild  counter-irritants,  or  blistering  and  poul- 
ticing,— if  he  finds  that  anyone  of  these  serves  him  best  he 
will  employ  that  one,  and  still  be  treating  the  case  after  the 
expectant  method;  if,  again,  he  finds  that  symptoms  yield 
best  to  opiates  he  will  employ  opiates. 

When  the  second  stage  is  reached,  and  deformity  appears, 
it  will  be  his  duty  to  adopt  such  measures  as  will  correct 
deformity  and  retain  the  limb  either  in  normal  position  or 
in  that  position  which  will  assist  in  bringing  about  the  best 
possible  result.  Some  employ  the  weight  and  pulley,  some 
the  crutches  and  high  shoe,  and  some  retentive  apparatus. 
The  aim  in  every  instance  is  the  same,  and  it  all  forms  a 
part  of  the  expectant  plan. 

If  abscess  forms,  it  is  his  duty  to  manage  this  on  what 
appears  to  him  correct  surgical  principles.  It  will  occur  to 
one  man  to  open  early,  thus  avoiding  the  formation  of  a 
large  sac  with  extensive  suppuration;  to  another  it  will 
seem  dangerous  to  touch  the  abscess  so  long  as  constitu- 
tional symptoms  are  absent.  Both  are  aiming  at  the  same 
object,  viz.,  the  minimum  amount  of  suppuration.  When 
it  becomes  clear  that  caries  necrotica  has  advanced  to  such 
an  extent  that  spiculae  of  loose  bone  are  present  in  the 


322  DISEASES  OF  THE  HIP. 

joint  cavity,  then  the  expectant  plan  demands  a  removal  of 
these,  as  it  would  a  removal  of  any  foreign  body  which 
militates  against  recovery.  The  minimum  amount  of  cut- 
ting is  of  course  expected.  As  a  rule,  no  operative  proce- 
dures are  resorted  to  for  the  removal  of  such  sequestra,  as 
their  presence  is  not  known  until  they  are  seen  projecting 
from  a  sinus.  Thus  a  pair  of  forceps  or  one's  fingers  suf- 
fice to  effect  a  removal. 

Again,  when  displacement  and  distortions  have  not  been 
prevented,  it  is  the  duty  of  him  who  follows  the  expectant 
plan  of  treatment  to  reduce  the  deformity  to  the  minimum. 
This  is  sometimes  done  with  apparatus,  and  sometimes  by 
means  of  the  surgeon's  knife. 

When  resolution  does  not  take  place,  and  when  the  sup- 
puration continues  to  the  production  of  lardaceous  changes, 
a  consistent  expectancy  would  demand  the  removal  of  the 
cause,  and  the  physician  who  follows  the  expectant  plan 
might  find  himself  some  day  excising  a  hip  joint.  It  is 
certainly  his  duty  to  give  his  patient  the  best  chance  of  life, 
and  if  he  accepts  the  facts  already  indubitably  established, 
he  will  most  assuredly  give  his  patient  that  which  offers 
about  the  only  chance  of  life.  If,  on  the  contrary,  he  does 
not  accept  the  facts  as  recorded  he  will  treat  the  symptoms 
as  they  arise;  will  administer  diuretics,  cathartics,  etc.,  etc. 

Such  then  constitutes  the  expectant  treatment,  and  it 
remains  now  to  elaborate  this  method,  and  to  ascertain 
whether  this  gives  us  the  best  cure. 

In  a  very  instructive  paper  published  in  the  Philadelphia 
Medical  Times  during  the  past  year,  Dr.  Oscar  Allis  raises 
the  question,  "What  is  the  best  cure  in  hip-joint  disease?" 
and  proceeds  to  show  that  "  nature's  cure"  is  the  best.  He 
claims  that  ankylosis  is  a  most  fortunate  termination,  and 
that  apparatus  should  be  employed  with  this  in  view.  Fur- 
thermore, the  angle  of  deformity  should  be  135°,  as  this  will 
subject  the  patient  to  the  least  inconvenience  in  any  voca- 
tion of  life.  The  shortening  of  the  limb,  he  further  claims, 
is  desirable,  in  that  it  necessitates  the  use  of  a  high  shoe. 
This  is  important,  because  with  the  loss  of  function  we  have 
arrest  of  development  in  the  femur,  and  by  this  arrest  of 
growth  "  the  knee  is  made  to  approximate  the  trunk;  and 
the  ankle,  by  the  elevation  of  the  shoe,  approximates  the 
position  of  the  knee." 

Now  while  Dr.  Allis's  views  may  seem  extreme  and  while 
they  give  us  an  apparently  gloomy  outlook,  they  are  just 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   323 

the  views  that  many  a  general  surgeon  comes  to  hold  who 
follows  his  cases  closely  and  who  bases  his  opinions  on 
final  results.  Dr.  Allis,  then,  represents  the  surgeon;  and 
while  he  admits  the  possibility  and  desirability  of  a  cure 
without  deformity  or  ankylosis,  he  confines  his  query  to 
the  cases  that  have  advanced  beyond  the  early  stages,  as 
the  following  quotation  will  show  : 

"  I  shall  have  no  reference  in  the  following  remarks  to 
the  early  manifestations  of  the  disease  and  its  possible 
cure.  An  eminent  surgeon  has  said  that  'nine-tenths  of 
the  cases  can  be  perfectly  cured  if  taken  in  time.'  Grant- 
ing this  to  be  true,  it  is  clinical  experience  that  nine  tenths 
of  the  cases  are  not  brought  to  us  in  the  early  stage  ;  and 
the  pertinence  of  my  query  still  applies  to  the  great  ma- 
jority of  cases  that  fall  victims  to  this  painful  crippling  dis- 
order." 

I  shall,  in  the  course  of  this  chapter,  aim  to  show  what 
the  expectant  plan  accomplishes,  and  whether  we  can  ex- 
pect any  better  results  than  Dr.  Allis  accepts  as  the  best, 
even  if  we  "get  our  cases  in  time."  And  a  few  remarks  on 
"  getting  our  cases  in  time"  may  not  be  irrelevant.  What 
does  one  mean  by  getting,  for  instance,  a  case  of  chronic 
articular  ostitis  of  the  hip  in  time  ?  Does  he  want  it  within 
the  first  week  of  the  appearance  of  signs,  or  does  he  want 
it  sooner  ?  Or  will  he  be  satisfied  if  he  gets  the  case  before 
the  second  stage  is  reached  ? 

The  fact  is  few  men  can  agree  on  this  point,  and  the 
anxious  mother  who  feelingly  asks,  "  Doctor,  have  I  come 
to  you  in  time  with  my  child  ?"  knows  too  well  by  the 
guarded  reply  that  it  is  a  difficult  question  to  answer. 

My  own  opinion  of  that  conditional  expression  "if  you 
had  only  come  to  me  early  enough,"  is  that  it  is  a  mischiev- 
ous assumption.  It  is  an  assumption,  because  it  assumes 
that  the  one  using  the  expression  is  surely  in  possession  of 
the  means  for  bringing  about  a  cure.  It  is  mischievous, 
because  it  seriously  reflects  on  the  previous  medical  attend- 
ant and  sows  the  seeds  of  dissatisfaction.  Besides,  it  is  a 
poor  science  that  will  not  allow  its  devotees  to  accept  the 
situation  and  get  good  results,  however  adverse  the  cir- 
cumstances. Let  a  man  be  honest  to  his  brother  practi- 
tioner, honest  to  his  patient,  honest  to  himself. 


324  DISEASES   OF  THE  HIP. 

THE   EXPECTANT    TREATMENT. 

With  a  knowledge  of  the  clinical  history  of  this  disease 
the  treatment  will  be  directed  to  the  exacerbations.  The 
relief  of  the  pain  is  the  most  important  object,  and  this 
being  accomplished  the  restlessness  at  night,  the  loss  of 
appetite,  etc.,  are  of  minor  consideration.  Rest  in  bed  and 
a  roller  about  the  hips  in  the  form  of  a  spica  bandage  gen- 
erally suffice  to  relieve  in  a  mild  exacerbation.  An  opiate 
is  seldom  necessary.  I  have  seen  many  cases  yield  promptly 
to  the  application  of  strong  tincture  iodine.  At  the  hos- 
pital blisters  are  applied  if  these  means  fail,  and  it  is  the 
rule  for  a  child  to  get  speedy  relief  after  such  treatment, 
especially  in  an  early  exacerbation. 

By  far  the  surest  method  is  fixation  and  traction.  The 
weight  and  pulley  sometimes  act  like  a  charm.  The  spasm 
is  overcome,  the  limb  is  supported,  and  the  child  falls 
asleep  without  fear.  This  exacerbation  being  passed,  no 
further  interference  is  called  for  until  the  next  one  ap- 
proaches. The  interval  is  occasionally  so  long  that  a  cure 
is  pronounced,  and  one  feels  that  he  has  really  accomplished 
a  good  result  by  very  simple  means. 

It  is  scarcely  necessary  to  mention  the  importance  at- 
tached to  cod-liver  oil.  This  is  used  freely  and  forms  the 
basis  of  all  medication.  Many  employ  an  alterative  tonic, 
such  as  the  syrup  of  the  iodide  of  iron,  or  the  bichloride 
of  mercury  with  the  compound  tincture  of  cinchona.  In- 
deed one  of  the  oldest  prescriptions  now  employed  in 
chronic  bone  and  joint  diseases  is  the  twenty-fourth  of  a 
grain  of  the  bichloride  to  a  drachm  of  the  compound  tinc- 
ture of  cinchona. 

When  there  is  much  lameness  crutches  form  a  valuable 
acquisition  to  our  armamentarium.  Whether  we  employ 
crutches  in  conjunction  with  a  high  shoe,  or  a  patten,  on 
the  sound  foot,  or  whether  they  are  employed  without  the 
shoe,  the  aim  is  to  rest  the  hip  and  at  the  same  time  to  per- 
mit out-of-door  exercise.  Those  who  adopt  what  is  known 
as  the  Hutchison  method,  viz.,  the  crutches  and  high  shoe, 
seldom  persist  in  it  longer  than  a  few  months.  Reliei 
comes,  i.e.,  an  exacerbation  is  passed,  in  a  short  time  the 
little  patient  becomes  more  confident  in  his  powers,  and  the 
crutches  are  soon  discarded;  while  the  physician  thinks  too 
that  they  have  served  their  purpose. 

The  appearance  of  a  cold  abscess  is  the  signal  for  a  good 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   325 

deal  of  alarm,  and  how  to  manage  these  pus  sacs  is  often  a 
serious  problem  in  the  course  of  an  expectant  treatment. 
Shall  they  be  left  severely  alone,  or  shall  they  be  opened 
early  ?  On  former  occasions  I  have  quoted  Billroth,  in 
favor  of  leaving  them  to  take  care  of  themselves.  For  many 
years  I  have  myself  deemed  it  the  part  of  wisdom  to  avoid 
surgical  interference.  The  rule  to-day  among  conserva- 
tives is  to  adopt  this  plan.  The  antiseptic  system  offers.  I 
think,  quite  as  good  an  outlook  as  does  the  process  of 
nature.  If  the  suppurative  process  in  the  bone  be  not  ex- 
hausted it  is  thought  that  the  opening  of  abscess  is  danger- 
ous, and  many  cases  that  seem  to  favor  this  view  can  be 
adduced.  On  close  analysis,  however,  these  cases  fail  to 
convince  one  that  the  incision  has  proven  more  detrimental 
than  a  spontaneous  opening.  Statistics  for  comparative 
study  are  wanting.  An  early  incision,  other  things  being 
equal,  has  the  advantage  of  preventing  the  formation  of  an 
extensive  pus  sac.  The  rule  holds  good,  however,  as  dis- 
tinctly enunciated  by  Billroth,  that  unless  one  is  prepared 
to  remove  the  diseased  bone  if  suppuration  be  not  checked 
the  abscess  should  not  be  touched. 

If  one  can  have  all  the  conveniences  of  the  antiseptic 
dressing  and  be  familiar  with  all  the  details  of  the  man- 
agement of  the  same,  then  I  should  strongly  urge  the 
early  opening.  Yet  how  few  in  private  practice,  and  es- 
pecially among  that  class  of  people  who  are  most  frequently 
affected  with  chronic  bone  disease,  can  command  the  con- 
veniences a  hospital  affords.  I  am  well  aware  of  this  fact, 
which  should  not  be  lost  sight  of.  These  abscesses  are  of 
trivial  import  to  the  orthopedist,  whether  he  practise  the 
expectant  plan  or  the  mechanical.  His  custom  is  to  leave 
them  alone  until  they  get  in  his  way  or  prove  annoying  or 
painful  to  the  patient;  then  he  makes  a  small  incision  or 
aspirates,  applies  a  compress,  and  awaits  the  progress  of 
events.  When  they  refill  he  opens  again.  It  is  the  prac- 
tice of  some  to  make  frequent  aspirations  removing  only  a 
small  portion  at  each  sitting.  I  know  well  that  many 
cases  have  abscess  after  abscess,  have  a  little  hectic  the 
fifth  or  sixth  day  after  spontaneous  opening,  experience 
very  little  inconvenience,  and  that  the  treatment  is  followed 
without  interruption.  It  has  long  been  a  question  in  my 
own  mind— not  by  any  means  original  with  me — whether 
suppuration  was  not  a  good  thing  for  an  articular  bone 
disease  I  believe  that  far  better  joints  are  secured,  far 


326  DISEASES   OF  THE   HIP. 

less  pain  and  tenderness  and  inconvenience  are  experienced 
in  after  life  in  those  hips  around  which  abscess  scars  can 
be  found  than  in  those  that  have  gone  on  to  ankylosis  with- 
out any  suppuration. 

So  then  I  advise  that  cold  abscesses  be  let  alone  until 
they  begin  to  cause  inconvenience. 

The  management  of  the  deformities  shall  be  reserved  for 
a  discussion  of  the  various  forms  of  apparatus.  Before 
leaving  the  expectant  treatment  I  propose  to  introduce  a 
few  typical  cases  in  order  that  its  merits  or  demerits  may 
be  justly  appreciated. 

The  impression  prevails  that  a  certain  class  of  cases 
can  be  so  far  relieved  that  no  deformity  will  remain.  I 
have  the  records  of  quite  a  number  of  such  cases;  but,  when 
collecting  them  for  publication,  I  find  the  notes  so  meagre 
on  certain  important  points  that  I  cannot  assure  myself 
even  of  the  correctness  of  the  diagnosis.  Take,  for  in- 
stance, a  case  like  the  following  : 

A  frail  cachectic  child,  two  and  a  half  years  of  age,  was 
brought  for  treatment  in  March,  1877.  A  diagnosis  of 
"hip-disease,  left  side?"  was  recorded,  and  the  only  other 
note  made  except  the  one  relating  to  his  delicate  appear- 
ance, was  that  the  disease  was  of  seven  weeks'  standing. 
The  treatment  employed  was  a  liniment  and  spica  ban- 
dage, cod-liver  oil  and  iron.  Six  weeks  later  it  was  recorded 
that  there  was  no  shortening,  but  apparent  lengthening  of 
the  limb,  and  that  the  thigh  was  fixed  on  the  pelvis  and  no 
motion  was  allowed  at  the  hip.  A  month  elapsed  and 
there  was  no  improvement.  The  same  treatment  was  con- 
tinued, and  in  September  (the  last  note  was  in  May)  I 
recorded  a  decided  improvement  in  every  respect.  There 
was  no  fulness  about  the  hip  and  he  walked  with  ease, 
scarcely  manifesting  any  lameness  whatever.  The  motion 
at  the  hip  was  limited  to  an  arc  of  only  twelve  degrees,  and 
the  limb  was  "still  rotated  outward  a  little,"  passive 
motion  in  rotation  being  resisted.  In  the  latter  part  of 
October  there  was  "  no  muscular  contraction,  no  atrophy, 
and  no  evidence  of  disease."  A  cure  was  recorded,  and  I 
was  at  a  loss  to  know  to  what  I  should  attribute  this  good 
result.  I  somehow  felt  well  convinced  that  I  had  a' true 
case  of  "hip-disease,"  and  yet  the  only  signs  I  had  obtained 
were  insufficient  to  qonvince  one  who  had  not  seen  the 
child. 

I  traced   the   case   at   the    end    of    three    months    and 


TREATMENT  OF   CHRONIC   ARTICULAR   OSTITIS.   327 

found  that  no  relapse  had  occurred.  It  was  in  the  latter 
part  of  June,  1878,  that  the  child  was  brought  to  me  with 
the  right  limb  advanced,  semi-flexed,  and  everted.  There 
was  also  much  reflex  muscular  spasm  at  the  hip  and  the 
boy  was  quite  lame.  All  these  signs  had  appeared  within 
a  week.  The  same  treatment  as  before  was  ordered,  and  in 
ten  days  "  the  limb  was  straight,  no  contraction,  motion  at 
joint  free  in  all  directions,  scarcely  any  lameness."  A 
week  or  two  later  I  could  not  detect  by  the  most  careful 
examination  any  sign  of  disease. 

Nothing  further  occurred  until  May,  1879,  when  he  again 
showed  decided  stiffness  at  the  right  hip.  It  could  not  be 
flexed  beyond  90°  or  be  extended  beyond  105°.  Indeed  it 
seemed  pretty  well  locked  at  this  last-named  angle.  There 
was  neither  shortening  nor  atrophy,  and  no  symptoms,  such 
as  pain  at  night,  restlessness,  loss  of  appetite,  etc.  These 
signs  were  of  brief  duration,  and  passed  away  as  quickly 
under  a  liniment.  I  made  it  my  duty  to  see  the  child 
every  two  or  three  months  thereafter,  and  up  to  the  begin- 
ning of  the  present  year  there  has  not  been  any  relapse, 
and  on  the  date  of  my  last  examination,  January  27th,  I 
could  not  find  any  sign  of  present  or  past  disease. 

When  I  first  saw  this  case  I  thought  it  hopeless,  and 
taking  together  the  hygienic  surroundings,  the  apparent 
improvidence  of  the  mother,  and  the  frailty  of  the  patient, 
I  could  not  form  any  other  opinion.  I  confess,  now,  that 
I  am  unable  to  make  a  diagnosis.  The  successive  invasion 
of  the  two  hips,  the  predominance  of  signs  over  symptoms, 
and  the  suddenness  of  the  different'exacerbations  leads  me 
to  regard  it  as  a  recurring  rheumatism.  I  have  searched 
diligently  for  any  rheumatism  in  father  or  mother  or  rela- 
tives near  and  remote,  have  instituted  the  same  search  for 
tuberculosis,  and  get  absolutely  negative  results. 

I  could  not  help  thinking,  however,  in  a  spirit,  perhaps, 
of  carping  criticism,  that  had  this  patient  been  subjected 
to  mechanical  treatment  a  brilliant  result  would  have  been 
claimed,  and  no  man  could  have  disputed  the  claim.  And 
yet  this  child  never  had  a  blister  applied,  never  had  any 
immobile  apparatus,  never  any  fixation  or  traction,  never 
any  rest  to  the  joint  other  than  the  rest  the  contracted 
muscles  gave  to  the  joint.  Compare  this  case  now  with  the 
following  : 

A  boy  aged  six  years,  whom  I  saw  in  Jime,  1880,  had 
resistence  to  flexion  and  to  abduction  as  the  extreme 


328  DISEASES  OF  THE  HIP. 

limits  were  reached.  He  had  been  lame  for  three  months, 
with  the  characteristic  hip  limp,  had  an  appreciable  change 
in  the  ilio-femoral  crease,  and  there  was  a  half-inch  atro- 
phy of  the  thigh.  Following  a  varicella  three  months  be- 
fore this  date  a  swelling  in  the  groin  had  presented,  yet 
there  was  no  history  of  any  marked  exacerbation.  The 
diagnosis  was  recorded  as  articular  ostitis  of  the  hip,  but 
an  interrogation  point  followed  the  record. 

The  boy  did  not  come  under  hospital  treatment,  and, 
curious  to  know  whether  the  diagnosis  had  been  correct,  I 
traced  the  patient  and  found  him,  February  22,  1883,  walk- 
ing very  easily;  yet,  on  close  inspection,  I  could  trace  a  little 
inequality  in  his  steps — the  space  covered  by  the  right  was 
shorter  than  that  covered  by  the  left.  There  was  still  a 
half-inch  atrophy  of  the  thigh  and  the  calf  was  now  a  half- 
inch  smaller  than  its  fellow.  External  rotation  was  cer- 
tainly less  complete  on  this  side  than  on  the  other,  and  I 
could  not  flex  the  limb  or  abduct  it  quite  to  the  normal 
limit.  The  parents  regarded  the  case  as  long  since  cured, 
and  for  all  practical  purposes  he  was  as  active  as  any  boy 
in  the  neighborhood. 

I  learned  that  he  went  under  treatment  shortly  after  I 
saw  him  in  1880,  at  a  similar  institution,  wore  a  hip  splint, 
continued  its  use  under  directions  for  nearly  a  year,  and  the 
splint  was  finally  removed  by  the  parents  on  their  own  re- 
sponsibility. I  could  not  get  a  history  of  any  exacerbations. 
Whether  the  disease  has  undergone  permanent  resolution, 
or  whether  there  be  an  unusually  long  remission,  it  is  diffi- 
cult to  decide.  At  all  e'vents  the  parents  and  the  neighbors 
credit  the  splint  with  the  cure.  So,  in  the  boy  whose  case 
is  reported  on  page  230,  the  prayers  of  the  priest  got  the 
credit  for  the  cure.  Cases  like  these,  with  such  well-marked 
signs  of  bone  disease,  are  extremely  rare.  I  have  seen  very 
many  in  which  I  have  felt  just  as  hopeful  of  complete  reso- 
lution, and  have  been  congratulating  myself  or  some  of  my 
surgical  friends  on  the  good  result,  when,  on  the  slightest 
provocation,  an  acute  exacerbation  would  declare  itself, 
dissipating  all  my  hopes. 

It  may  be  pertinent  to  inquire  what  the  expectant  treat- 
ment will  do  for  a  chronic  articular  ostitis  of  the  hip,  if 
begun  in  the  first  stage.  From  my  records  I  have  selected 
some  cases,  a  report  of  which  will  show  what  the  method, 
in  its  popular  acceptation,  can  accomplish. 

A  girl,  aged  seven  years,  came  under  treatment  near  the 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   329 

beginning  of  June,  1879,  giving  a  tuberculous  family  history, 
and  the  history  of  a  lameness  of  three  months'  standing. 
At  the  same  time  her  lameness  began,  or  shortly  thereafter, 
she  complained  of  pain  in  the  groin  and  night  pains  soon 
developed;  in  other  words,  the  first  exacerbation  appeared 
early  and  persisted  at  least  two  months.  My  notes  of  her 
condition  are  pretty  full,  and  instead  of  giving  them  in  de- 
tail, I  shall  simply  state  that  there  were  present  nearly  all 
the  signs  of  a  typical  bone  lesion  of  the  hip  in  the  early 
stage.  An  error  in  diagnosis,  I  think,  was  out  of  the  ques- 
tion. Under  the  hospital  regimen,  cod-liver  oil  and  an 
alterative  tonic,  there  were  no  further  exacerbations  of  any 
significance  during  the  year  succeeding  her  admission. 
The  signs  gradually  disappeared,  and  in  August,  1881,  I 
recorded  an  arrest  of  the  disease  because  I  could  not  de- 
tect any  lameness,  any  reflex  muscular  spasm,  any  resist- 
ance to  movements  carried  to  normal  limits,  any  atrophy, 
or  any  joint  tenderness.  I  did  find,  however,  a  slight 
change  in  the  contour  of  the  nates,  a  little  flattening,  and 
a  little  enlargement,  apparently  of  the  trochanter.  The 
lesion  was  probably  confined  to  the  diaphysis,  and  perhaps 
eventually  encroached  on  the  trochanteric  centre  of  ossifi- 
cation. 

A  case  that  came  under  my  observation  for  the  first  time 
in  the  spring  of  1878  was  instructive  for  many  reasons.  The 
patient  was  of  the  same  sex  as  the  one  just  reported  and 
was  four  years  of  age.  In  this  case  the  lameness  was  more 
marked  in  the  afternoon,  in  the  other  it  was  more  marked 
in  the  forenoon.  The  father  of  this  child  was  under  my 
care  for  an  osteo-sarcoma  involving  the  knees,  and  of  this 
he  eventually  died; 

In  the  beginning  of  the  year,  three  months  prior  to  her 
admission  to  the  hospital,  she  began  to  walk  lame,  and  it 
was  very  clearly  reported  that  the  lameness  came  on  im- 
mediately after  a  fall.  The  signs  found  on  my  examina- 
tion were,  slight  eversion  of  the  foot  and  advancing  of  the 
limb,  a  slight  yet  perceptible  hip  limp,  a  broadened  natis, 
a  crease  shortened  and  lowered,  a  deformity  at  an  angle 
of  150°,  with  very  little,  if  any,  motion  by  reason  of  the  re- 
flex contraction,  and  a  half-inch  atrophy  of  the  thigh. 
Negatively  I  found  an  absence  of  effusion  or  infiltration 
about  the  trochanter,  no  shortening,  no  bone  or  joint  ten- 
derness. When  asked  to  locate  the  pain  she  placed  hei 
hr.nd  on  the  outer  side  of  the  knee.  The  treatment  adopted 


33O  DISEASES   OF  THE  HIP. 

was  the  same  as  in  the  other  case,  and  in  June,  as  she  was 
convalescing  from  an  attack  of  rubeola  an  exacerbation  of 
pain,  restlessness  at  night,  etc.,  developed.  Relief  not 
coming  promptly,  a  fly-blister  was  applied  to  the  hip,  and 
for  a  week  subsequent  to  its  application  she  rested  much 
better.  A  month  elapsing  the  symptoms  returned,  and  it 
was  noted  that  the  parts  about  the  hip  were  very  tender. 
A  second  blister  was  applied,  and  the  child  was  not  allowed 
to  move  around  unless  by  means  of  a  rolling-chair. 

It  was  fully  a  month  before  any  decided  relief  was  ap- 
parent, and  during  the  next  eight  months  not  an  un- 
toward symptom  developed.  In  June,  1879,  a  note  was 
made  that  the  thigh  could  be  completely  flexed  without 
pain  or  resistance,  and  could  be  extended  to  160°  with 
equal  facility.  She  had  no  pain,  and  walked  with  great 
ease.  The  medicines  were  discontinued. 

Nothing  noteworthy  occurred  during  the  remainder  of 
the  year;  only  it  was  from  time  to  time  observed  that  the 
movements  were  becoming  less  free;  indeed,  on  December 
1 2th,  I  found  the  arc  of  motion  only  one  half  as  great  as  it 
was  in  June.  Again,  in  February  of  the  following  year 
the  arc  was  much  greater  than  it  was  in  December.  A  cir- 
cumscribed fulness  had  appeared  near  the  trochanter,  and 
an  abscess  was  thought  inevitable. 

During  the  years  1 880-81  she  had  recurring  attacks  of 
naso-facial  erysipelas,  but  no  symptoms  of  any  moment  ref- 
erable to  the  hip.  The  tumor  gradually  diminished  in 
size,  and  the  final  result  of  the  case,  as  noted  June  loth, 
1881,  was  as  follows:  a  girl  in  apparently  good  health,  able 
to  walk  with  very  little  inconvenience,  although  the  toes  and 
ball  of  the  foot  served  for  the  whole  soie.  There  was  an 
inch  real,  and  an  inch  and  a  half  practical  shortening;  an 
inch  and  a  half  atrophy  of  thigh,  and  an  inch  of  the  calf; 
joint  surfaces  smooth  and  free  from  tenderness;  flexion 
perfect,  and  extension  nearly  perfect;  a  little  resistance 
offered  as  the  limb  was  abducted  toward  the  normal  limit; 
rotation  permissible  over  about  one  half  the  normal  arc; 
the  abscess  sac  barely  appreciable. 

It  will  be  seen  from  the  foregoing  that  the  case  presented 
a  joint  pretty  completely  locked  in  the  early  stage,  that 
the  exacerbations  were  few,  that  an  abscess  appeared  and 
the  contents  of  the  same  were  probably  removed  by  ab- 
sorption, and  that  a  very  mobile  joint  was  obtained  despite 
the  shortening  and  atrophy  of  the  limb. 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.  331 

I  should  like  to  have  more  such  cases  to  report,  but  can- 
dor compels  me  to  state  that  these  results  are  exceptionally 
good. 

It  is  seldom  that  an  abscess  does  not  sooner  or  later 
appear,  and  it  is  seldom  that  it  takes  the  same  course  as 
the  one  in  the  case  reported. 

The  following  is  an  illustration  of  how  poorly  a  certain 
number  respond  to  the  expectant  treatment:  In  April,  1879, 
there  came  into  the  hospital  a  fairly-nourished  boy  four 
and  a  half  years  of  age,  who  had  been  favoring  the  left 
limb  for  four  months.  The  family  history  furnished  nothing 
definite  as  to  predisposition,  yet  it  is  fair  to  say  that  few 
facts  were  attainable.  It  was  only  two  weeks  before  his 
admission  that  an  exacerbation  showed  itself,  so  that  when 
I  first  saw  him  the  symptoms  were  very  well  marked. 
There  were:  a  deformity  approximating  that  characteristic 
of  the  second  stage,  a  decided  limp  peculiar  to  chronic 
ostitis,  a  very  limited  amount  of  motion,  and  an  angle  of 
deformity  at  135°.  The  pain  was  referred  to  the  groin,  and 
the  limb  would  not  tolerate  much  handling.  The  usual 
treatment  was  adopted  and  the  exacerbation  soon  passed 
off,  to  be  followed  three  months  later,  however,  by  another. 
For  his  pains  at  night  a  cantharidal  plaster  was  applied 
and  the  parts  poulticed  as  is  the  custom.  Ten  days  after- 
ward relief  came,  and  the  next  exacerbation — two  months 
elapsing — ended  with  an  abscess  which  occupied  the  outer 
side  of  the  thigh.  This  increased  to  a  large  size  and 
opened  spontaneously  three  months  after  its  appearance. 
Hectic  fever  occurred  on  the  sixth  day,  but  did  not  continue 
longer  than  forty-eight  hours.  About  this  time  another 
abscess  could  be  recognized  in  the  gluteal  region,  springing 
apparently  from  the  digital  fossa.  The  tumor  spread  rap- 
idly throughout  this  region,  and  opened  near  the  sacro- 
iliac  synchondrosis  within  a  month.  This  was  the  third 
week  in  January,  1880,  and  on  the  eighth  of  February  I  re- 
corded the  following  note  : 

"Is  greatly  emaciated,  eyelids  puffy,  feet  cedematous. 
Liver  dulness  extends  four  fingers'  breadth  below  free 
border  of  the  ribs;  the  abdomen  is  distended;  an  open 
sinus  above  Poupart's  ligament  is  discharging  quite  freely, 
and  there  is  another  over  the  trochanter.  The  thigh  is 
flexed  at  an  angle  of  90°,  and  is  strongly  adducted." 

He  died  from  exhaustion  four  and  a  half  months  after- 
ward, and  on  autopsy  I  found  no  ankylosis,  but  destruc- 


332  DISEASES  OF  THE  HIP. 

tion  of  the  capsular  ligament  in  its  upper  and  lower  fourths, 
where  one's  finger  could  be  easily  inserted,  encountering 
eroded  bone  dark  in  color  and  foetid  in  odor.  The  iliac 
bone,  including  the  acetabulum,  exhibited  no  lesion  what- 
ever, either  superficially  or  on  section.  On  vertical  section 
of  head,  neck,  and  shaft  the  lesions  found  were,  absence  of 
articular  cartilage,  about  one  half  of  the  necrotic  head  the 
remainder  lying  in  fragments  in  the  acetabulum,  a  little  ir- 
regularity in  the  line  of  epiphysial  union,  and  about  a 
half  inch  below  this  line  a  yellowish  spot  in  the  centre  of 
ossification  of  the  neck. 

I  could  not  find  a  vestige  of  the  ligamentum  teres.  The 
liver  was  enormously  enlarged  and  on  section  had  a 
waxy  appearance,  the  iodine  test  also  fully  confirming  the 
diagnosis  of  lardaceous  degeneration.  This  was  an  excellent 
case  for  early  interference,  and  the  lesion  as  shown  post 
mortem  was  one  for  which  the  expectant  treatment  could 
do  nothing.  The  evolution  was  unusually  rapid,  and  the 
appearance  of  lardaceous  changes  came  on  very  soon  after 
the  opening  of  the  abscess. 

A  single  other  case  will  illustrate  some  practical  points 
in  the  management  of  this  disease.  It  was  in  a  boy  twelve 
years  of  age,  whom  I  saw  first  in  December,  1880.  The  ma- 
ternal history  was  decidedly  tuberculous.  In  the  early  part  of 
the  year  the  boy  began  to  walk  lame,  and  the  lameness  was 
uninterrupted  by  an  exacerbation  until  five  weeks  before 
his  admission  to  the  hospital.  The  right  limb  was  appar- 
ently lengthened,  a  little  advanced,  and  rotated  outward. 
The  changes  in  nates,  the  lordosis,  the  inability  to  walk, 
the  locking  of  the  joint  at  an  angle  of  135°,  were  salient 
points  in  enabling  one  to  recognize  this  as  the  typical  sec- 
ond stage.  There  was  an  extreme  degree  of  tenderness  in 
and  about  the  joint.  This  was  regarded  as  a  fine  case  for 
blistering,  and  a  blister  was  promptly  applied.  The  relief 
was  only  temporary  as  an  abscess  made  its  appearance 
within  three  months  on  the  outer  aspect  of  the  thigh  lower 
third.  It  grew  rapidly  and  was  soon  opened  by  incision. 
In  spite  of  tonics  and  stimulants  the  boy  rapidly  lost  flesh, 
and  in  less  than  two  months  another  abscess  involved  the 
whole  of  the  gluteal  region,  causing  a  vast  deal  of  suffering. 
During  the  summer  he  had  very  few  days  without  pain,  he 
grew  thin,  and  the  limb  assumed  a  very  awkward  position. 
In  November,  1881,  he  was  removed.  The  angle  of  de- 
formity was  120°,  and  the  case  seemed  hopeless.  He  was 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.  $33 

taken  to  a  home  that  was  devoid  of  all  hygienic  qualifica- 
tions, a  home  where  intemperance  prevailed,  and  yet  within  a 
month  the  most  marked  improvement  had  taken  place.  In 
the  following  May  I  saw  him  and  the  sinuses  were  closed, 
his  general  health  was  excellent,  and  the  disease  seemed  to 
be  arrested.  Tracing  him  out  during  the  past  spring  I 
found  that  no  exacerbation  had  occurred  since  he  left  the 
hospital.  The  deformity  was  about  135°  and  he  was  quite 
active.  The  point  I  wished  to  bring  out  is  this,  viz.,  that 
patients  sometimes  reach  a  stage  in  the  progress  of  the 
disease  where  removal  from  a  hospital  offers  the  only  hope 
of  recovery.  They  become  depressed,  get  homesick,  and 
all  remedies  fail.  Let  the  home  be  ever  so  humble,  ever  so 
unhealthy,  the  change  often  works  wonders. 

The  claims  that  are  set  up  for  the  expectant  treatment 
are,  that 

1.  As  good  results  are  obtained  as  by  other  methods. 

2.  There  is  less  expense  and  less  inconvenience  to  the 
patient. 

3.  The  nutrition  of  the  limb  is  not  impaired. 

With  regard  to  the  first  claim,  it  is  not  proven.  Regard- 
ing the  second,  I  am  aware  that  the  expense  of  apparatus 
is  a  serious  drawback  in  this  specialty,  and  many  patients 
do  object  to  the  cumbersomeness  of  these  appliances,  many 
of  which  are  ill-fitting  and  fail  to  meet  the  indications.  The 
extensive  abuse  of  mechanical  appliances  has  served  to 
bring  them  into  disrepute.  So  far  as  my  own  observation 
goes,  well-fitting  splints  render  the  patients  very  comforta- 
ble, and  the  relief  they  experience  from  pain  and  muscular 
spasm  is  so  great  that  it  is  difficult  to  bring  about  a  sus- 
pension of  their  use. 

Concerning  the  third  claim,  the  clinical  history  abun- 
dantly  proves  that  the  nutrition  of  the  limb  does  suffer  with 
or  without  the  use  of  apparatus;  indeed  it  is  a  clinical  fact 
that  atrophy  is  one  of  the  most  valuable  signs  in  diagnosis. 

My  own  conclusion,  after  twelve  years'  daily  experience 
with  the  commonly  accepted  expectant  treatment,  is,  that 

1.  In  a  very  few  cases  of  chronic  articular  ostitis  of  the 
hip  good  results  are  obtained. 

2.  In  the  large  majority  of  cases  it  is  utterly  inadequate 
either  to  arrest  the  disease  or  to  secure  the  best  possible  re- 
sult, irrespective  of  the  stage  in  which  the   treatment  is 
begun. 

3.  Whenever  one  can  feel  assured  that  he  has  a  genuine 


334  DISEASES  OF  THE  HIP. 

case  of  chronic  articular  ostitis  of  the  hip,  science  demands, 
humanity  demands,  that  the  so-called  expectant  method 
should  form  no  part  of  the  treatment.  The  rule  admits  of 
few  exceptions. 

4.  When  one  is  in  doubt  as  to  the  diagnosis,  and  the  pre- 
ponderance of  evidence  seems  to  be  against  the   lesion  be- 
ing one  in    the  bones  entering  into  the  articulation,  the 
expectant  method  should  be  adopted  pending  the  period 
of  doubt. 

5.  If  the  evidence  is  in  favor  of  a  bone  lesion,  abandon 
the  expectant  treatment. 

I  speak  advisedly  on  this  subject,  and  I  speak  fortified  by 
a  faithfully  recorded  experience. 

Cases  like  the  following  certainly  make  an  impression. 
It  made  a  painful  impression  on  me,  and  I  charged  it  up  to 
the  credit  side  of  expectant  treatment.  The  case  has  already 
been  reported  in  the  chapter  on  clinical  history,  and  may 
be  found  on  p.  244.  The  points  are  briefly  these:  He  was 
six  years  of  age,  was  admitted  in  January,  1873,  had 
a  poor  family  and  a  poor  personal  history,  had  been 
limping  since  June,  1872,  had  had  one  or  two  rather 
severe  exacerbations ;  on  admission  his  limp  was  very 
slight — scarcely  perceptible — the  gluteal  signs  were  slight 
yet  sufficiently  well  marked,  the  deformity  was  nil, 
flexion  could  be  made  to  90°  without  pain  or  resist- 
ance, there  was  no  joint  tenderness,  no  atrophy,  no  short- 
ening. A  diagnosis  was  easily  reached,  however,  the  dis- 
ease not  having  advanced  beyond  the  first  stage.  A  blister 
was  ordered  forthwith,  but,  on  reflection,  was  postponed 
because  he  rested  well  at  night.  A  liniment  of  iodine  bella- 
donna and  soap  with  a  spica  bandage  was  used.  In  February 
he  began  to  sleep  poorly,  to  walk  with  more  difficulty,  and 
Fowler's  solution  was  administered.  The  symptoms  sub- 
sided in  a  week,  and  in  May  the  mother  talked  of  remov- 
ing him.  On  examination  then  he  stood  squarely  on  both 
feet  with  limbs  parallel,  and  scarcely  favored  the  right  hip 
in  walking.  There  was  no  articular  or  periarticular  tender- 
ness that  I  could  elicit,  and  flexion  of  the  thigh  could  easily 
be  made  beyond  90°. 

In  June  it  was  thought  that  a  cure  had  been  effected  so 
active  had  he  become,  still  a  careful  examination  would  de- 
tect a  few  signs.  Early  in  July  he  was  climbing  some  scaf- 
folding, and  fell  striking  the  hip.  He  was  scarcely  able  to 
walk  the  same  day,  and  cold-water  dressings  and  rest  fail- 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   335 

ing  to  give  relief,  a  blister  was  applied  a  few  evenings  later 
:  was  poorly  applied,  and  a  week  or  two  afterward  a 
second  one  was  applied,  getting  a  good  vesication.  The 
poultices  were  used  as  is  the  custom— a  fresh  one  every 
six  hours  for  three  days. 

About  this  time  two  large  boils  appeared  on  the  left  hip 
but  were  considered  the  effect  of  the  vesication.     The  left 


FIG.  33. — ARTICULAR  OSTITIS,  BOTH  HIPS. 

hip  presented  signs  indicative  of  bone  disease,  and  it  was 
not  long  before  the  second  stage  was  reached.  In  the  mean- 
while the  disease  on  the  right  side  was  advancing  to  the 
third.  Abscess  formed  in  gluteal  region  and  on  posterior 
surface  of  thigh,  deformity  became  extreme,  the  boy  be- 
came quite  helpless  fora  long  time,  and  was  only  able  to  get 
about  in  a  rolling  chair.  Finally  in  February,  1875,  he  was 
able  to  leave  the  rolling-chair,  and  his  mode  of  progression 


336  DISEASES   OF  THE  HIP. 

is  well  illustrated  by  a  drawing  from  life.  See  Fig.  32,  which 
represents  very  accurately  the  deformity  of  both  hips.  At 
this  time  the  liver  was  found  enlarged.  After  prolonged 
suppuration  he  was  finally  discharged  as  incurable  in  Sep- 
tember, 1876. 

My  restrictions,  I  would  have  it  understood,  apply  to  the 
method  as  popularly  understood.  If  the  system  were  freely 
carried  out,  if  not  only  the  aim  were  to  relieve  the  exacer- 
bation in  the  early  stage,  but  to  prevent  and  correct  deform- 
ity, or  to  bring  about  that  deformity,  if  deformity  needs 
must  come,  which  will  secure  the  greatest  usefulness  of 
the  limb,  then  I  should  say,  By  all  means  retain  the  treat- 
ment, yet  never  hesitate  to  abandon  it  in  individual  cases 
where  it  becomes  clearly  ineffectual. 


CHAPTER  XVI. 

TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS,  BY  CRUTCHES 
AND  HIGH  SHOE  WITH  OR  WITHOUT  FIXATION. 

I.  THE  PHYSIOLOGICAL  TREATMENT  OF  DR.  HUTCHISON. 
II.  COMBINATION     OF    THE    PHYSIOLOGICAL   TREATMENT 
WITH  FIXATIVE  SPLINTS. 

1.  The  simplest  form    of  mechanical  treatment  is   that 
brought   forward   by  Dr.  Hutchison   of   Brooklyn,  and  is 
called   by   him    the    Physiological   Method.     The  body  is 
supported  in  walking  by  means  of    axillary  crutches,  and 
the  limb  diseased  is  allowed  to  swing,  its  own  weight  being 
relied  upon  to  make  the  necessary  amount  of  traction,  while 
the  peri-articular  muscles  by  their   reflex  spasm  serve  to 
secure  the  necessary  amount  of  fixation.     The  treatment  is 
not  complete,  of  course,  without  the  high  shoe,  or  patten, 
on  the  sound  foot. 

I  have  not  classed  the  weight  and  pulley  known  as 
Buck's  extension  as  a  separate  form.  This  is  employed 
now  more  as  an  adjuvant  than  as  an  independent  mode.  It 
is  employed  at  times  in  connection  with  the  various  splints 
and  appliances,  and  is  used  expectantly  to  relieve  urgent 
symptoms  or  persisting  signs.  When  the  indications  are 
met,  it  is  discontinued.  This  would  be  more  properly  a 
step  in  the  expectant  plan  of  treatment. 

2.  Closely  allied  to  the  physiological  method  is  the  plan 
employed  by  Mr.  Hugh  Owen  Thomas,  of  Liverpool,which  is 
a  combination  of  the  physiological  and  the  fixative  methods. 
The  principle    involved    is   immobility,  and    this    is    best 
secured,  Mr.  Thomas  claims,  by  limiting  the  movements  of 
the  joints  immediately  above  and  immediately  below  the 
hip-joint. 

3.  Fixative  splints,  whose  sole  object  is  to  retain  the  limb 
in  position,  resisting  thereby  the  muscular  spasm  that  is  so 
important   an   element   in    the   production  of  deformity. 
These  are  called  appliances  for  securing  rest. 


338  DISEASES  OF  THE   HIP. 

4.  Splints  whose  object  is  not  only  to  protect  the  joint 
but  to  make  traction.  These  splints  embody  what  the 
English  choose  to  call  the  American  idea. 

I.  THE  PHYSIOLOGICAL  TREATMENT. 

In  1879,  when  Dr.  Hutchison  so  zealously  and  so  ably 
advocated  this  plan  of  managing  hip-joint  cases,  many  of 
us  wondered  why  it  had  not  occurred  to  us  before,  and 
many  more  of  us  fancied  that  we  had  at  last  been  freed 
from  the  thraldom  of  splints.  It  seemed  very  simple  and 
very  useful.  Somehow  it  has  always  been  my  misfortune 
to  meet  with  cases  that  are  grave  from  the  beginning.  I 
seem  to  meet  with  hip-disease  which  involves  the  bony 
structures;  and,  get  the  cases  ever  so  early,  I  find  them  ex- 
ceedingly  tedious,  exceedingly  slow,  and  so  prone  to  re- 
lapses that  I  am  rendered  consequently  slow  myself  in 
publishing  cures. 

Since  1879  I  have  employed  this  method  in  quite  a  num- 
ber of  cases,  and  I  am  not  ready  now  to  give  an  analysis 
of  the  same.  Some  of  my  best  cases  are  still  under  treat- 
ment. I  have  seen  enough,  however,  of  its  practical  work- 
ing to  form  a  very  fair  estimate,  I  think,  of  the  value  of  the 
method.  I  look  upon  it,  moreover,  as  but  a  part  of  the 
expectant  plan,  and,  in  so  far  as  it  gives  protection  to  the 
joint,  I  am  its  warmest  advocate.  I  am  convinced,  though, 
that  it  does  not  prevent  deformity,  and  I  have  not  had  any- 
thing like  the  success  that  is  recorded  in  Dr.  Hutchison's 
book,  published  in  1880.  Let  me  give  one  of  my  best 
cases;  indeed,  it  is  the  only  one  out  of  a  large  number  that 
has  done  well,  and  yet  the  the  case  is  not  complete. 

In  July,  1878,  I  began  treating  a  little  girl  whose  case 
had  advanced  to  the  second  stage.  Her  disease  had  lasted 
since  March.  When  I  saw  her  the  limb  was  held  rigidly 
flexed  at  an  angle  of  80°,  and  the  adduction  was  very  great. 
She  lived  in  the  country,  and  as  she  had  just  passed  an 
exacerbation,  nothing  was  done  further  than  to  prescribe  a 
liniment  and  an  alterative  tonic.  I  did  not  see  the  case 
again  until  March,  1879;  it  had  been  under  another  physi- 
cian, but  the  same  prescription  had  been  followed.  The 
deformity  was  as  great  as  when  I  saw  it  in  July.  The 
crutches  and  high  shoe  were  now  ordered;  and,  as  her 
father  was  a  man  of  much"  mechanical  ingenuity,  he  fully 
appreciated  the  idea,  and  had  directions  followed  to  the 


TREATMENT   OF  CHRONIC   ARTICULAR   OSTITIS.    339 

letter.  In  May  and  in  July  I  recorded  an  increase  in  the 
mobility  of  the  joint.  She  found  much  relief  from  the 
treatment;  had  had  only  an  insignificant  exacerbation,  and 
in  December  I  found  that  the  thigh  could  be  easily  flexed 
to  an  acute  angle,  could  be  extended  to  135°  before  any 
resistance  was  encountered,  and  could  be  abducted  and 
adducted  over  small  arcs.  I  could  rotate  the  limb,  too, 
quite  easily,  and  there  was  no  apparent  shortening,  but  a 
real  shortening  of  a  half-inch.  In  the  following  March  I 
made  a  similar  note.  In  September,  1881,  the  treatment 
having  been  continued  the  meanwhile,  I  found  that  I  could 
extend  the  limb  to  150°,  but  I  recognized  in  the  iliac  fossa 
a  well-marked  tumor,  which  I  took  to  be  an  abscess.  A 
week  before  this  note  was  made  she  had  fallen,  striking 
the  ilium  near  the  anterior-superior  spinous  process,  and 
next  day  complained  of  pain  at  the  knee.  I  could  not 
detect  any  joint  tenderness,  and  could  not  perceive  any 
diminution  in  the  arcs  of  motion.  I  gave  no  attention  to 
the  tumor,  and  in  January,  1882,  it  had  reached  the  size  of 
a  hen's  egg,  and  filled  the  groin.  It  had  caused  no  pain 
or  inconvenience,  but  the  shortening  of  the  limb  was  now 
one  inch.  For  the  tumor  I  ordered  the  hot  douche  twice  a 
day.  In  March  there  was  a  practical  shortening  of  three 
inches,  and  a  real  shortening  of  one  inch.  The  tumor  was 
as  large  as  ever,  and  there  was  a  marked  tenderness  of 
the  joint.  Over  the  trochanter  a  shade  of  fulness  could  be 
detected.  She  was  crying  in  her  sleep,  and  was  generally 
indisposed.  Hot  fomentations  at  night  were  ordered,  and 
the  crutch  and  high  shoe  continued  by  day. 

In  July  the  tumor  was  perceptibly  smaller;  otherwise 
there  was  no  change.  I  did  not  see  the  case  again  until 
February  of  the  present  year,  when  the  angle  of  deformity 
was  135°.  Flexion  could  be  made  to  45°,  rotation  and  ab- 
and  adduction  could  be  made  over  small  arcs.  As  the 
child  stood  the  limb  was  rotated  outward.  I  looked  long 
and  diligently  for  the  abscess,  and  had  to  record,  "  Not 
found."  From  the  umbilicus  to  the  lower  border  of  the 
internal  malleolus  there  were  two  and  a  half  inches  short- 
ening (practical),  and  from  the  anterior-superior  spinous 
process  one  and  a  half  inches  (real). 

My  last  note  was  on  the  twenty-seventh  of  July.  The 
limb  hangs  at  angle  of  150°;  is  easily  flexed  to  45°.  There 
is  no  infiltration  about  the  trochanter,  in  groin,  or  illiac 
fossa.  The  tip  of  the  trochanter  is  one  inch  above  N61a- 


340  DISEASES   OF  THE   HIP. 

ton's  line,  and  the  shortening  is  the  same  as  measured  in 
February.  My  impression  is  that  I  shall  get  a  cure  that 
will  compare  favorably  with  any  case  that  can  be  shown. 

It  will  be  seen  that  after  three  years'  treatment  the  limb 
shortened  one  inch,  abscess  formed  and  disappeared,  and 
a  most  excellent  degree  of  mobility  was  obtained.  And 
yet  I  cannot  help  contrasting  this  with  other  cases  I  have 
treated  without  crutches  and  high  shoe.  Take  for  in- 
stance the  case  on  page  329  This  girl,  it  will  be  seen,  was 
in  the  hospital,  not  in  the  country;  had  a  bad  family  his- 
tory and  a  bad  personal  history.  She  had  a  hip,  in  the 
early  part  of  her  hospital  treatment,  that  was  locked 
against  movement.  Later  the  movements  were  very  good, 
an  abscess  appeared,  disappeared.  Finally  came  out,  with 
an  inch  and  a  half  shortening,  and  joint  function  nearly 
perfect.  The  duration  of  treatment  was  three  years. 

Another  girl  I  had  under  observation  a  number  of  years, 
with  sinuses  and  abscesses,  finally  made  a  fair  recovery, 
with  the  limb  in  a  very  serviceable  position.  The  treat- 
ment had  been  constitutional,  and  in  February,  1879,  I 
made  a  note  that  the  ulcers  and  sinuses  were  healed;  that 
she  had  very  little  deformity,  very  fair  motion,  no  pain  or 
tenderness,  and  that  she  walked  with  much  ease.  At  this 
time  she  was  ten  years  of  age,  and  her  left  hip  had  been 
the  one  about  which  the  disease  had  spent  itself. 

About  the  first  of  October,  of  the  same  year,  she  began 
to  complain  of  pain  about  the  right  hip,  and  four  or  five 
days  later  I  made  an  examination,  finding  it  impossible  to 
flex  the  thigh  to  a  minimum  extent,  even  without  pain; 
considerable  infiltration  in  the  groin,  and  much  joint  ten- 
derness. Comparative  measurements  were  unsatisfactory, 
because  of  the  shortening  in  the  other  limb.  The  length 
of  this  limb,  however,  was  twenty-six  and  a  half  inches.  I 
decided  upon  the  physiological  treatment,  but  the  exacer- 
bation was  so  acute,  and  the  other  limb  was  so  insecure, 
that  I  waited  a  few  days  to  devise  ways  and  means.  In 
the  mean  time  a  blister  was  ordered.  A  temporary  relief 
followed  its  application,  but  ten  days  later  she  was  con- 
fined to  her  bed,  and  all  the  symptoms  were  aggravated. 
Movements  in  all  directions  were  resisted,  and  the  limb 
was  held  flexed  at  an  angle  of  140°.  She  fairly  made  night 
hideous  with  her  shrieks,  and  had  to  be  propped  up  with 
pillows  to  secure  any  rest  at  all.  Another  blister  was 
ordered.  This  was  the  last  of  October,  and  three  days 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   341 

later  I  found  her  quite  comfortable.  She  had  slept  quietly 
all  night.  With  much  care  I  could  flex  the  limb  to  120°, 
and  extend  to  150°.  Abduction  and  rotation  were  resisted  as 
soon  as  attempted.  I  could  not  detect  any  joint  tenderness. 

Pathologically  speaking,  I  regarded  the  case  as  one  be- 
ginning as  an  acute  coxo-femoral  synovitis.  It  was  not 
many  days  before  I  had  her  on  a  pair  of  crutches,  with  a 
six-inch  high  shoe  on  the  foot  of  the  left  limb.  It  required 
two  months  to  teach  her  how  to  get  about  on  her  apparatus, 
and  before  she  was  able  to  move  around  unassisted  another 
exacerbation  came  on  rendering  her  quite  helpless.  The 
sisters  of  the  girl  were  very  persevering  in  teaching  her  to 
walk,  and  by  the  following  May  I  was  surprised  to  find 
with  what  ease  she  moved  about.  The  limb  was  apparently 
lengthened,  the  toe  not  clearing  the  floor  well  as  she  walked. 
In  June  I  had  twelve  ounces  of  lead  attached  to  the  heel, 
with  the  desired  result.  The  case  progressed  slowly, 
marked  by  frequent  exacerbations,  and  it  was  not  until 
December,  1881,  that  the  treatment  was  discontinued.  The 
right  limb  then  measured  twenty-seven  and  a  quarter 
inches.  The  limb  was  very  nearly  straight,  yet  the  move- 
ments were  restricted  to  very  small  arcs.  No  suppuration 
had  occurred,  and  there  was  no  infiltration  about  the  joint. 
At  present  writing  she  walks  with  comparative  ease  by 
reason  of  compensating  deformities.  The  angle  of  deform- 
ity on  the  right  side  is  160°,  on  the  left  130°.  and  movements 
on  both  sides  are  restricted  in  all  directions.  The  joints 
are  practically  ankylosed. 

This  certainly  was  a  very  fair  result,  if  we  consider  the 
difficulties  under  which  I  labored.  It  was  certainly  better 
than  the  result  obtained  in  that  of  a  case  I  put  under  the 
same  treatment  in  the  summer  of  1879. 

In  May,  1878,  I  diagnosticated  a  chronic  articular  ostitis 
in  a  boy  six  years  of  age,  after  he  had  been  walking  lame 
for  two  weeks.  I  did  not  get  the  case  to  treat  however 
until  a  year  afterward.  He  wore  a  long  splint  the  latter 
half  of  the  intervening  year,  and  when  he  came  again  under 
my  observation  the  angle  of  deformity  was  165°  and  the 
limb  was  only  a  halMnch  short.  The  boy  was  so  irritable 
that  a  satisfactory  examination  as  to  motion  was  out  of  the 
question.  Suffice  it  to  say,  this  seemed  to  me  a  very  good 
case  for  the  physiological  treatment,  and  I  forthwith  put  it 
into  effect.  It  was  at  least  two  months  before  he  learned 
to  use  the  crutches  well,  and  in  January  of  the  following 


342  DISEASES  OF  THE  HIP. 

year,  as  the  deformity  seemed  to  be  increasing,  I  had  a  piece 
of  lead  attached  to  the  heel  of  the  shoe  on  the  suspended 
limb.  The  joint  became  more  securely  locked,  and  about 
this  time  the  first  of  a  series  of  abscesses  made  its  appear- 
ance, the  locality  being  the  space  beneath  the  tensor  vagi- 
nae femoris. 

It  is  unnecessary  to  follow  the  case,  through  these  suc- 
cessive abscesses,  through  the  pains  and  the  increasing  de- 
formity. It  is  enough  to  know  that  the  treatment  has  been 
faithfully  and  persistently  followed;  that  the  disease  has 
progressed  from  bad  to  worse  without  a  reassuring  interval; 
that  lardaceous  degeneration  has  declared  itself  by  unmis- 
takable signs,  and  the  limb  is  now  ankylosed  at  an  angle 
of  about  130°,  is  at  least  two  inches  shorter  than  its  fellow; 
and  that  the  inguinal  region,  the  gluteal  region,  and  the 
thigh  on  both  lateral  and  posterior  aspects  presents  one  net- 
work of  sloughing  and  burrowing  ulcers,  open  sinuses  and 
cicatrices. 

And  yet  this  case  does  not  present  so  melancholy  a  his- 
tory as  that  of  a  boy  aet.  nine  years,  who  contracted  disease 
of  the  bones  entering  into  the  formation  of  the  hip  in  1877. 
It  had  reached  the  second  stage  when  I  first  saw  the  case 
in  February,  1879.  It  was  under  the  care  of  the  family 
physician,  and  was  sent  to  me  simply  for  advice.  I  advised 
the  crutches  and  high  shoe.  In  May  he  was  formally  com- 
mitted to  my  care,  and  I  recorded  his  angle  of  deformity, 
135°,  his  shortening,  a  quarter  of  an  inch,  the  absence  of 
joint  tenderness,  and  the  limitation  of  movements.  The 
limb  did  not  seem  heavy  enough  to  make  the  desired  trac- 
tion, and  ten  ounces  of  lead  was  added. 

A  month  later  the  angle  of  deformity  was  90°  and  the 
patient  was  in  the  height  of  a  very  acute  exacerbation. 
The  next  note,  a  month  afterward,  records  the  subsidence 
of  the  exacerbation,  but  the  deformity  was  unrelieved.  It 
was  a  month  before  I  recognized  that  a  dislocation  had 
taken  place  since  the  treatment  had  been  employed,  and 
he  was  admitted  to  the  hospital,  where  a  more  careful  ex- 
amination revealed  the  following  interesting  facts:  four 
and  a  quarter  inches  shortening,  the  trochanter  above  Nela- 
ton's  line,  ability  to  flex  the  thigh  to  an  acute  angle,  in- 
ability to  extend  beyond  90°,  an  extreme  degree  of  adduc- 
tion, the  presence  of  what  seems  to  be  the  head  of  the  bone 
on  dorsum  ilii,  and  an  absence  of  any  signs  pointing  tc 
suppuration. 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   343 

An  anaesthetic  was  administered  while  the  deformity  and 
shortening  were  overcome.  A  leather  splint  was  applied, 
and  the  weight  and  pully  employed  for  a  fortnight.  He  was 
then  discharged  from  the  hospital,  but  continued  under  treat- 
ment as  an  out-patient.  The  limbs  were  equal  in  length, 
and  he  was  put  on  the  crutches  again,  the  high  shoe  com- 
pleting the  outfit.  He  wore  the  leather  splint  three  months, 
and  then  relied  solely  on  the  crutches  and  high  shoe. 

From  this  time  hence  his  suffering  began  anew.  Night 
extension  was  employed,  but  abscess  formed,  the  limb 
shortened,  and  the  deformity  came  on  slowly.  He  con- 
tinued to  go  about  for  nearly  a  year,  but  finally  took  to 
his  bed,  the  suppuration  became  profuse,  the  deformity  ex- 
treme, and  later  still  the  symptoms  of  lardaceous  degenera- 
tion declared  themselves.  He  lingered  until  the  spring  of 
the  present  year. 

I  have  notes  of  several  cases  under  this  form  of  treatment 
for  a  year  or  two,  deriving  no  benefit,  and  finally  coming 
under  mechanical  treatment.  It  is  a  clinical  fact  that  pa- 
tients using  the  crutches  and  high  shoe  do  feel  encouraged 
during  the  first  few  months,  and  that  they  exhibit  a  certain 
temporary  improvement.  Many  of  us,  no  doubt,  shared 
Dr.  Hutchison's  enthusiasm  when  the  treatment  was  yet 
new,  and  we  heartily  subscribed  to  the  peroration  found  on 
page  32  of  his  work  on  Orthopaedic  Surgery: 

"  What  a  boon  it  is  to  get  rid  of  the  paraphernalia  with 
which  the  diseased  limb  was  formerly  encumbered — the 
harness  and  the  trappings,  the  weight  and  pulleys  and  ad- 
hesive plaster,  the  perineal  bands  and  the  iron  splints,  and  all 
the  discomforts  which  their  use  implies!" 

I  was  peculiarly  impressed  with  that  sentiment,  and,  in 
my  own  copy  can  be  found  a  long  mark  of  approval  about 
the  passage.  Would  that  I  could  subscribe  to  it  now!  I  had 
had  no  experience  then;  I  have  an  experience  now.  In  my 
interviews  with  various  surgeons  I  have  learned  that  the 
treatment  has  been  disappointing.  In  Dr.  Bradford's  article 
on  The  Treatment  of  Hip-Disease,  published  in  the  Boston 
Medical  and  Surgical  in  November,  1880,  his  conclusions 
even  at  that  time  were  that  "  it  meets  certain  indications, 
but  cannot  be  relied  upon  in  all  the  phases  of  the  disease. 
Patients  treated  according  to  this  method  illustrate  that 
at  some  stages  and  in  some  cases  the  natural  fixation  is  ap- 
parently sufficient,  and  that  at  times  but  little  extension  is 
n§e.d.ed;  but  it  is  also  clear  that  in  many  cases  the  weight 


344  DISEASES   OF  THE  HIP. 

of  the  limb  is  not  enough  to  overcome  muscular  contrac- 
tion, prevent  deformity,  and  give  the  patient  the  greatest 
amount  of  freedom  from  the  discomfort  due  to  disease  at 
the  hip-joint.  As  a  means  of  extension  it  is  imperfect,  for 
the  reason  that  it  is  efficient  only  when  the  patient  is  upright; 
for  fixation,  it  does  not  perfectly  guard  against  involun- 
tary motion  occurring  during  sleep;  it  also  is  not  cer- 
tain to  protect  the  joint  from  jar,  for  in  practice  many  chil- 
dren when  not  suffering  from  a  painful  joint  will  be  found 
occasionally  to  kneel  upon  the  affected  limb,  or  take  a  step, 
unless  watched  more  closely  than  is  usually  practicable." 

I  have  thus  quoted  Dr.  Bradford  at  length,  because  all 
the  points  he  makes  are  illustrated  by  cases;  and  were  I  to 
formulate  my  own  conclusions,  I  should  embody  the  same 
ideas. 

II.  FIXATION   SPLINTS    ASSISTED    BY    THE    PHYSIOLOGICAL 

METHOD. 

There  are  a  number  of  splints  that  bear  the  names  of  the 
different  surgeons,  who  have  either  invented  them  or  em- 
ploy them,  and  while  some  are  not  expected  to  require  any 
additional  assistance,  they  all  are  meant  to  serve  one  special 
object,  viz.,  fixation.  All  surgeons  at  the  present  day  who 
employ  such  appliances  have  come  to  recognize  the  impor- 
tance of  suspending  the  body  on  crutches  so  that  the  idea 
of  fixation  and  rest  may  be  all  the  more  fully  carried 
out.  They  all  aim  at  immobility  of  the  joint,  with  extension. 
There  are  really  very  few  that  are  constructed  with  these 
two  ends  in  view.  These  maybe  enumerated  in  the  follow- 
ing order: 

i.  Dr.  Hamilton's  Wire-Gauze  Splint. — Closely  allied 
to  this  is  the  wire-gauze  splint  of  Mr.  Barwell.  The 
accompanying  diagrams  represent  a  front  view  and  a 
rear  view  of  the  apparatus.  It  will  be  seen  that  it 
consists  of  an  iron  wire  frame  moulded  to  the  pelvis  and 
thigh.  This  frame  is  covered  with  wire  gauze.  The  whole 
is  kept  in  place  by  a  pelvic  band  and  a  broad  thigh  band, 
both  of  which  are  secured  by  buckles.  To  secure  exercise 
in  the  open  air  crutches  are  use'd.  With  a  high  shoe,  the 
weight  of  the  limb  will  thus  prove  an  extending  force.  I 
have  no  personal  knowledge  of  the  value  of  this  splint,  do 
not  even  know  of  any  cases  that  have  been  thus  treated, 
hence  can  draw  no  conclusions  as  to  its  value. 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTlTIS.   345 


FIG.  34.— HAMILTON'S  SPLINT— FRONT 
VIEW. 


FIG.  35.— HAMILTON'S  SPLINT  —  REAR 
VIEW. 


2.  Dr.  Vance  s  Leather  Splint. — On  the  same  principle  Dr. 
Ap  M.  Vance  has  constructed  a  splint  of  saddle  leather. 
The  Doctor  selects  the  best  saddle  skirting,  and  with  soft 
paper  takes  a  pattern  of  the  sound  hip  in  the  position  it  is 
desirable  to  fix  the  diseased  hip.  When  this  pattern  is  re- 
versed it  will  fit  the  other  hip,  and  the  leather  when  pre- 
pared for  application  will  have  somewhat  the  shape  of  the 
drawing  in  Fig.  35. 

The  lettering  represents  the  following  parts  :  P.  B.  is  the 
pelvic  band,  and  is  seen  to  be  of  good  width  ;  T.  B.,  is  the 
thigh  band;  T.,  tongues  of  thinner  leather  and  sewed  to 
the  splint  after  it  has  been  moulded  and  fitted  to  the  parts. 
These  are  applied  in  finishing  up  the  splint;  S.  H.,  shoe 
hooks,  also  attached  in  the  finishing  process;  R.,  copper 
rivets  for  securing  the  gusseted  portion;  A.,  a  gusset  to 
permit  of  adapting  the  splint  to  the  pelvis. 

The  limb  is  placed  in  the  desired  position  in  one  of  three 
ways,  according  to  the  exigencies  of  the  case.  i.  If  but 
little  muscular  spasm  exists  it  can  be  easily  forced  into  posi- 


34* 


DISEASES  OF  tttE 


tion  by  the  hand,  and  securely  maintained  pending  the  dry- 
ing of  the  leather.  2.  If  the  spasm  and  contraction  be 
too  great  for  this  procedure,  the  weight  and  pulley  can  be 
employed  for  a  few  days  or  weeks,  as  the  case  may  be.  3. 
In  the  opinion  of  some  surgeons  it  is  better  to  administer 
an  anaesthetic  and  bring  the  limb  into  position  at  once  by 


e>~ 

.• 

<3  : 

'e. 

O; 

P.b, 

Q? 

O 

&al 

• 

a/3 

£jt& 

e> 
e> 

°f 

o 

FIG.  36. — LEATHER  SPLINT  BEFORE  IT  is  MOULDED  TO  THE  HIP. 

force.  By  reason  of  our  ignorance  of  the  exact  stage  of 
the  pathological  process  I  deem  this  last  process  of  reduc- 
ing deformity  exceedingly  hazardous.  Of  course  there  are 
periods  when  it  can  be  done  with  impunity,  but  I  have  seen 
so  many  distressing  symptoms,  so  many  disastrous  exacer- 
bations follow  in  the  wake  of  these  operations,  that  I  always 
raise  my  voice  against  the  practice,  especially  in  the  pre 


TREATMENT   OF   CHRONIC  ARTICULAR   OSTITIS.   347 

suppurative  stages.  The  leather  is  now  immersed  in  very 
hot  water  long  enough  to  make  it  thoroughly  pliable.  Then, 
while  the  hip  is  in  that  position  we  desire,  mould  the  leather 
about  pelvis  and  thigh,  securing  it  with  a  roller.  In  from 
fifteen  to  twenty  minutes  it  will  "  set,"  and  be  sufficiently 
hard  to  admit  of  removal  without  losing  the  shape.  In 
order  to  give  one  time  to  dress  and  complete  the  splint  the 
position  of  the  !imb  should  be  secured  by  weight  and  pul- 
ley. If  there  be  no  occasion  for  haste  in  completing  the 
apparatus  the  leather  can  be  left  on  the  parts  for  twelve 
hours,  and  then,  when  removed  for  purposes  of  completion, 
the  limb  will  be  less  likely  to  resume  its  original  mal- 
position. 

The  edges  are  pared  down,  thegusseted  portion  is  riveted 
as  desired,  the  hooks  and  tongues  are  attached,  and,  if  one 
prefer  a  perforated  splint,  holes  can  be  made  with  a  belt- 
punch  without  weakening  to  any  great  extent  the  apparatus 
thus  constructed.  To  guard  against  excoriation  or  undue 
pressure  over  the  crista  ilii  fenestra  are  cut  in  these  por- 
tions of  the  splint,  and  if  it  be  necessary  to  take  special 
precautions  against  the  recurrence  of  deformity  a  strip  of 
steel  can  be  riveted  in  front,  as  seen  in  Fig.  36,  which  rep- 
resents the  dressing  in  use.  It  will  be  seen  also  from  this 
figure  that  the  parts  are  protected  by  some  soft  material, 
such  as  the  leg  of  a  pair  of  closely-fitting  drawers.  If 
abscesses  already  exist,  or  form  subsequent  to  the  begin- 
ning of  this  treatment,  openings  in  the  leather  are  made 
when  desirable.  The  special  advantages  claimed  for  this 
splint  are,  that  it  is  easy  of  construction,  easily  fitted,  and 
can  be  cleansed  with  soap  and  water  without  the  least  detri- 
ment to  the  material.  Furthermore,  if  it  be  desirable  to 
change  the  position  of  the  limb,  it  can  be  done  as  in  the 
first  instance,  the  splint  can  be  immersed  again  in  hot  water, 
and  reset  as  before. 

This  treatment  in  intelligent  hands  I  know  yields  good 
results.  The  joint  is  protected,  a  good  position  of  limb 
maintained,  the  patient  is  comfortable,  and  the  disease  is 
placed  under  the  control  of  the  surgeon.  The  objection 
that  is  urged  against  all  short  splints  can  be  brought 
against  this,  viz.,  that  it  does  not  immobilize  the  joints 
above  and  below  the  hip.  It  is  very  easy,  however,  to  make 
the  bands  wider,  and  thus  meet  this  objection.  For  very 
young  children  who  cannot  be  taught  the  use  of  crutches 
it  does  not  fully  protect  against  alterations  in  the  position 


34-8  DISEASES   OF  THE  HIP. 


FIG.  37.— DR.  VANCE'S  LEATHER  SPIINT, 


TREATMENT  OF  CHRONiC  ARTICULAR  OSTlTIS.   349 

of  the  neck  of  the  femur.  They  will  walk  when  not  suffer- 
ing an  exacerbation,  and  the  weight  is  necessarily  thrown 
on  the  limb. 

3.  The  Liverpool  Method. — Mr.  Hugh  Owen  Thomas,  of 
Liverpool,  England,  has,  for  a  number  of  years,  employed 
a  method  of  fixation  that  seems  to  secure  this  object  better 
than  most  of  the  splints  now  in  use.  At  the  same  time, 
while  disavowing  any  attempt  or  desire  even  at  extension, 
he  uses  in  conjunction  with  his  splint  the  high  shoe  and 
crutches.  He  certainly  takes  enough  precaution  to  pro- 
tect the  joint  from  injury,  and  the  zeal  with  which  he  pur- 
sues his  practice,  and  the  favor  it  is  meeting  with  through- 
out Great  Britain,  bespeak  for  it  more  consideration  than 
the  surgeons  in  our  own  country  seem  willing  to  give.  In 
Chapter  III.  of  the  second  edition  of  his  work  on  "  Diseases 
of  the  Hip,  Knee,  and  Ankle  Joints,"  he  gives  very  explicit 
instructions  about  the  making  of  the  apparatus,  and  it 
would  seem  that  any  surgeon  possessed  sufficient  mechanical 
tact  to  construct  an  instrument  for  himself.  The  patient  is 
to  stand  with  weight  on  the  sound  limb,  while  the  foot  of 
the  side  diseased  rests  on  a  block,  or  book,  or  cushion, 
sufficiently  high  to  bring  the  spinal  column  perfectly 
straight.  Ordinarily,  in  cases  that  have  not  advanced  be- 
yond the  first  stage,  the  height  of  the  foot-rest  sufficient 
to  secure  this  vertical  bearing  will  be  one  inch.  To  secure 
the  best  fit,  the  whole  of  the  posterior  aspect  of  the  body, 
including  the  lower  limbs,  must  be  divested  of  clothing. 

The  materials  necessary  for  work  are: 

1.  A  flat  piece  of  malleable  iron  long  enough  to  extend 
from  the  lower  angle  of  the  scapula  to  the  junction  of  the 
middle  with  the  lower  third  of  the  leg — just  where  the  calf 
begins.      This  should  be  an  inch  in  width  and  a  quarter  of 
an  inch  in  thickness,  for  an  adult,  and  three  quarters  of  an 
inch  by  three  sixteenths,  for  children. 

2.  Three  strips  of  hoop-iron:  a,  one  for  the  chest  an  inch 
and  a  half  in  width  by  one  eighth  of  an  inch  in  thickness, 
and  for  its  length  about  four  inches   less  than  the  circum- 
ference of  the  thorax;  b,  another  for  the  thigh,  three  quar- 
ters of  an  inch  in  width  and  one  eighth  of    an   inch   in 
thickness,  and  its  length   two  thirds   the  circumference  of 
the  limb   in  its  upper  third;  c,  another  band  of    similar 
strength' for  the  calf,  and  equal   in  length  to  one  half  the 
circumference  of  the  limb  at  this  point. 

3.  A  set  of  wrenches  with  which  to  shape  the  iron  bars. 


DISEASES  OF  THE  HIP. 


These  are  made  by  a  smith,  and  properly  tempered.  Those 
marked  i  are  enough  for  all  practical  purposes;  2  is  an- 
other form,  and  may  serve  a  better  purpose  at  times  than 
the  other  pair.  To  any  one  who  makes  any  pretension  to 
the  practice  of  orthopedic  surgery  these  or  similar  wren- 
ches are  very  valuable. 

This  long  iron  bar  now,  with  the  patient  in  the  position 
above-named,  must  be  moulded  over  the  buttock  along  the 
course  of  the  sciatic  nerve,  through  the  popliteal  space,  and 
over  the  calf  to  the  lower  end.  These  precautions  are 


FIG.  38. — SERVICEABLE  WRENCHES  IN  FITTING  ORTHOPEDIC  APPLIANCES. 

necessary  to  avoid  excoriations.  Indeed,  one  of  the  great 
secrets  of  success  in  all  forms  of  apparatus  is  the  extreme 
care  one  takes  in  the  application  of  the  same.  The  lumbar 
portion  of  this  upright  will  be  a  plane  surface,  in  fact,  Mr. 
Thomas  insists  on  it  being  "  invariably  almost  a  plane  sur- 
face." It  is  necessary  to  rotate  this  baron  its  axis  at  a 
point  just  above  the  buttock  curve,  in  order  to  adapt  it  to  the 
individual  patient,  as  some  are  more  plump  than  others. 
This  can  be  easily  accomplished  with  the  wrenches. 

The  next  step  in  the  preparation  of  the  splint  is  to  mould 
this  longer  strip  of  hoop-iron  into  a  chest-band.  It  is  to 
be  riveted  to  the  top  of  the  upright  bar  at  a  point  one 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.  35 1 

third  its  length,  measuring  from  the  end  corresponding 
with  the  side  diseased.  The  shape  will  be  oval,  and  this 
will  be  found  necessary  to  prevent  the  splint  from  turning. 
The  thigh  strip  is  now  fitted  in  the  same  manner  as  the  one 
for  the  chest,  and  is  to  be  secured  to  the  upright  at  a  point 
from  one  to  two  inches  below  the  ilio  fermoral  crease.  The 
third,  or  calf  strip,  is  fitted  in  the  same  way,  and  riveted  at 
the  lower  end.  These  three  are  called  crescents,  and  are 
distinguished  as  chest,  thigh,  and  calf  crescents  of  the 
splint.  If  it  be  desirable  to  immobilize  both  hips  when 
both  are  diseased,  for  instance,  the  other  upright  is  con- 
nected to  the  first  by  a  cross-bar  in  the  lumbar  portion. 
When  the  patient  or  friends  do  not  object  Mr.  Thomas  pre- 
fers this  double  splint,  even  in  cases  where  only  one  joint  is 
diseased,  as  he  can  then  feel  more  certain  of  its  efficacy. 

The  crescents  being  riveted  to  the  upright  the  instrument 
is  ready  to  be  padded  and  covered.  For  the  padding  a 
single  thickness  of  No.  i  boiler  felt  is  preferable,  and  for  the 
covering  basil  leather  as  used  by  saddlers  is  preferable  to 
any  other  material.  A  saddler  can  do  this  with  very  little 
inconvenience.  The  upper  or  chest  crescent  is  secured  to  the 
body  by  a  strap  and  buckle.  Suspenders  are  used  over  the 
shoulders,  as  seen  in  Figs.  38  and  39 ;  the  lumbar  portion 
is  secured  by  a  common  roller  bandage,  and  the  limb  por- 
tion in  the  same  way. 

With  the  patten  high  enough  to  clear  the  foot  of  diseased 
limb  and  the  crutches  the  outfit  is  complete,  and  Fig.  38 
represents  an  anterior  view  of  the  patient  ready  for  exercise. 
Even  when  the  instrument  has  been  carefully  made  and 
comes  from  the  shop,  more  moulding  and  fitting  is  fre- 
quently required  of  the  surgeon  himself.  The  crescents 
may  have  to  be  shaped  differently  to  get  the  upright  in 
the  proper  line,  and  salient  points  will  require  a  little  more 
bending.  Indeed,  however  lightly  one  may  think  of  the 
apparatus  as  a  therapeutic  agent,  he  cannot  but  help  ad- 
mire the  great  attention  to  details  which  Mr.  Thomas  ex- 
hibits in  describing  his  plan.  Some  men  may  have  the  best 
instrument  in  the  world  and  get  the  poorest  results,  and 
vice  versa. 

The  surgeon  must  not  think  his  work  done  when  the 
splint  is  applied.  He  must  see  it  from  day  to  day,  for 
weeks  perhaps,  and  aim  to  get  the  best  possible  fit. 

Inward  and  outward  rotation  of  the  limb,  abduction,  and 
adduction  can  be  frequently  corrected  if  not  too  exaggerated 

[-  h  \ 


LC 


352 


DISEASES   OF  THE  HIP. 


by  the  uses  of  the  wrenches  while  the  instrument  is  on  the 
patient.    These  little  tendencies  can  easily  be  thus  corrected. 


FIG.  39.— FRONT  VIEW  OF  MR.  THOMAS'S  SPLINT  APPLIED. 

For  bandages  flannel  rollers  are  the  best,  and  should  be 
employed  by  all  means  in  young  children. 

For  the  correction  of  deformity,  the  upright  is  bent  in 


TREATMENT   OF   CHRONIC  ARTICULAR  OSTITS.   353 

the  buttock  portion  and  the  splint  is  applied  in  the  deformed 
position.     From  time  to  time  the  curve  of  the  upright  is 


FIG.  40.-A  POSTEROR  VIEW  OK  THE  THOMAS  SPLINT. 

lessened  by  degrees  at  the  point,  A,  indicated  by  the  arrow 
in  Fig.  40, 


354 


DISEASES   OF  THE   HIP. 


Fio.  4i.-MoDE  OF  GRADUAL  CORRECT.ON  QF  DEFORMITY  WITH  THE  THOMAS  SPLINT 


TREATMENT   OF  CHRONIC  ARTICULAR   OSTITIS.   355 

I  have  thus  given  in  considerable  detail  the  construction 
and  the  mode  of  application  of  this  instrument,  and  have 
confined  myself  pretty  closely  to  Mr.  Thomas's  descrip- 
tion. For  still  more  of  detail,  however,  I  must  refer  to 
the  work  itself. 

During  the  first  three  or  four  months  after  the  applica- 
tion of  the  splint  the  patient  is  confined  to  the  bed,  and  a 
change  in  the  appliance  is  never  made  unless  under  the 
direct  supervision  of  the  surgeon.  While  any  changes 
are  being  made  the  dorsal  decubties  must  be  maintained, 
and  under  no  circumstances  must  the  sitting  posture  ever 
be  tolerated.  While  the  patient  is  thus  confined  to  bed 
during  this  period  Mr.  Thomas  calls  it  his  first  stage  of 
treatment. 

The  second  stage  of  treatment  begins  when  the  patient 
leaves  the  bed.  Then  the  high  shoe  and  the  crutches  are 
employed.  There  is  no  definite  length  of  time  for  the  con- 
tinuance of  this  stage,  as  it  depends  upon  the  rapidity  of- 
atrophy.  It  must  be  "  continued  until  the  limb  is  well 
atrophied  about  the  great  trochanter."  Considering  the 
variableness  of  atrophy  this  seems  to  me  a  very  uncertain 
guide.  A  better  one  in  my  opinion  would  be  the  length  of 
time  since  the  patient  had  had  an  exacerbation. 

The  disappearance  too  of  all  inflammatory  products  in 
the  neighborhood  of  the  hip  should  also  be  an  element  in 
determining  the  duration  of  this  stage.  Splints  that  immo- 
bilize the  joint  surrounded  by  bone  disease  should  be  worn 
from  one  to  two  or  three  years.  I  am  arguing  now  against 
contingencies;  I  am  arguing  in  favor  of  giving  the  joint 
every  possible  chance. 

In  the  third  stage  of  treatment  the  splint  is  removed  at 
night,  and  replaced  during  the  day,  the  patient  still  using 
the  crutches  and  patten.  The  duration  of  this  period  is 
briefly  given  by  the  author  as  "  a  certain  period."  By  ref- 
erence to  a  few  reported  cases  it  will  be  seen  to  extend 
over  a  period  of  from  two  to  five  months. 

The  fourth  stage  of  treatment  begins  with  the  removal  of 
the  splint  altogether.  The  crutches  and  patten  are  still 
retained  for  a  few  weeks,  or  months,  until  the  surgeon  is 
satisfied  that  the  cure  is  permanent. 

One  naturally  wishes  to  know  what  the  results  are.  Do 
the  results  as  obtained  justify  us  in  subjecting  the  child  to 
so  much  apparent  discomfort  ?  And  again,  is  the  discom- 
fort greater  than  that  where  perineal  crutches  are  used? 


356  DISEASES  OF  THE  HIP. 

During  the  past  summer  a  medical  friend,  who  has  for 
several  years  devoted  his  attention  chiefly  to  orthopedic 
surgery,  spent  some  weeks  with  Mr.  Thomas,  and  he 
went  over  strongly  prejudiced  in  favor  of  the  "American 
method."  This  friend  called  to  see  me  on  his  return,  and 
I  asked  him  particularly  about  the  discomfort  to  which  Mr. 
Thomas's  patients  were  subjected.  He  replied  by  saying 
that  he  saw  very  few  signs  of  any  discomfort,  that  the 
patients  seemed  happy,  and  that  good  results  were  certainly 
the  rule.  Analyzing  a  few  years  ago  the  few  reported  cases 
Mr.  Thomas  has  published,  I  found:  one  received  in  first 
stage,  duration  of  disease  and  angle  of  flexion  not  specified, 
length  of  treatment  twelve  months,  the  first  three  months 
of  which  required  the  horizontal  position  in  bed,  with  an 
ultimate  "cure"  for  the  result;  four  in  second  stage,  two  of 
which  were  of  five  months'  standing,  indicated  by  any 
given  angle  of  flexion,  say  150°,  the  other  two,  three  and 
four  months  standing  respectively,  not  indicated  by  any 
given  angle  of  flexion;  three  were  "cured,"  one  "  recovered," 
one  kept  the  bed  three  months,  one  five  months,  one  nine 
months,  and  one  twelve  months;  five  were  received  in  the 
third  stage,  and  in  three  relief  was  afforded,  one  recovered 
in  three  years'  time,  and  one  died  twenty  days  after  an  ex- 
cision. 

In  Dr.  Bradford's  paper,  to  which  allusion  has  before  been 
made,  the  method  is  not  warmly  advocated.  From  a  few 
cases  he  had  under  observation  he  reports  that  "  one,  an 
active  child  too  young  for  crutches,  visibly  lost  in  general 
condition  from  the  confinement  of  the  splint.  Another 
gained  both  locally  and  generally,  but  complained  of  the 
irksomeness  of  the  apparatus.  A  third  has  improved  and 
is  free  from  active  symptoms,  but  is  inclined  to  lay  aside 
his  crutches  and  step  on  the  affected  limb." 

The  following  case  is  reported  by  Dr.  Bradford  as  show- 
ing the  value  of  extension  over  this  fixation  splint: 

"A  boy  aged  five,  with  hip-disease,  had  been  treated  for 
several  weeks  by  complete  fixation  in  bed,  and  an  extension 
by  weight  and  pulley.  The  symptoms,  which  had  been 
acute,  had  subsided.  There  was  no  swelling,  pain,  or  ten- 
derness about  the  hip,  and  the  case  had  been  progressing 
favorably  for  some  time.  A  Thomas  splint  was  applied 
and  accurately  fitted.  On  the  following  night  there  was 
severe  nocturnal  pain,  which  increased  on  the  next  night. 
The  next  day  the  hip  was  found  swollen  and  tender,  and  the 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.  357 

limb  sensitive  on  jar.  The  symptoms  all  disappeared  im- 
mediately on  removal  of  the  splint  and  the  readjustment  of 
the  extension.  The  boy  has  since  been  progressing  well, 
as  before.  The  coincidence  was  so  marked  that  there  could 
be  no  doubt  that  the  disease  had  been  aggravated  by  the 
splint,  and  that  this  exacerbation  was  stopped  by  its  re- 
moval. It  should  be  said  that  in  six  other  cases  where 
Thomas  splints  were  applied  nothing  of  this  sort  has  oc- 
curred." 

The  objections  urged  against  immobilization  are,  to  my 
thinking,  without  ground,  and  I  believe  with  Mr.  Thomas 
that  the  closer  one  can  come  to  securing  perfect  rest  the 
better  the  final  result  will  be.  It  seems  a  rational  theory 
he  advocates,  viz.,  that  the  movements  to  which  a  joint  are 
subjected  by  muscular  irritation,  by  strain  or  by  jar,  by  in- 
flammatory products  excited  by  blistering,  or  by  any  other 
means,  contribute  largely  to  the  ankylosis  so  common  in 
this  disease.  In  our  treatment  by  the  expectant  method 
or  by  extension  splints,  we  caution  the  patient  against  falls 
or  strains  of  any  kind,  knowing  that  these  little  mishaps 
are  often  the  direct  cause  of  an  exacerbation,  and  knowing 
that  an  exacerbation  means  the  extension  by  contiguity  of 
the  inflammatory  process  to  the  joint  and  to  the  periarticu- 
lar  tissues. 

If  this  plan  will  secure  a  movable  joint  the  inconveni- 
ences are  as  nothing.  At  all  events  let  American  surgeons 
give  it  a  trial. 


CHAPTER  XVII. 

THE  TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS  BY  EX- 
TENSION APPARATUS,  WITH  OR  WITHOUT  MOTION. 

This  plan  is  almost  exclusively  American,  and  to  Ameri- 
can surgeons  we  are  indebted  for  a  large  number  of  appli- 
ances, all  of  which  claim  these  same  principles. 

The  one  practical  idea,  however,  to  which  all  these  splints 
tend  is  immobilization  or  fixation,  with  the  associated  idea 
of  motion  if  desirable.  The  aim  of  all  is  to  transfer  the  weight 
of  the  body  from  the  articulation  to  the  perineum  or  the 
axillae.  Nearly  all  the  forms  of  mechanical  appliances  for 
the  hip  possess  screws  of  some  kind  that  will  permit  motion 
or  arrest  motion.  In  the  preceding  chapter  the  apparatus 
described  is  not  constructed  with  this  idea  of  motion  in 
view.  Extension  and  counter-extension,  unremitting  and 
invariable,  is  what  some  of  those  who  have  constructed 
splints  insist  upon;  while  others,  more  rational  in  their  ideas, 
modify  those  ideas  according  to  the  indications. 

A  history  of  the  evolution  of  the  extension  treatment  is 
not  pertinent  to  this  discussion,  as  all  text-books  and  all 
papers  lead  us  up  the  different  steps.  The  original  Davis 
splint  is  not  used  now  I  believe  by  any  surgeons,  and  hence 
I  have  not  represented  it  in  these  pages.  It  has  no  pelvic 
band,  and  is  inferior  as  an  ischiatic  crutch  to  the  splint  de- 
vised by  Dr.  Andrews,  of  Chicago.  As  a  means  of  exten- 
sion, however,  it  served  a  good  purpose.  Better  splints 
followed. 

Similar  in  principle  and  not  so  extensively  figured  in  the 
text-books  is  the  Washburn  splint.  It  has  no  screws  or 
ratchets,  and  the  lower  end  fits  into  a  piece  of  steel  attached 
to  the  shank  of  the  shoe,  while  the  extension  is  made  by 
means  of  adhesive  strips  attached  to  the  limb.  The  tabs 
pass  through  holes  in  the  shoe,  and  are  fastened  to  buckles 
connected  with  the  foot-piece.  It  is  represented  in  Fig.  41. 

Dr.  Bauer,  of  St.  Louis,  employs  a  splint  consisting  of 
inside  and  outside  bars,  with  attachment  to  shoe.  There 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   359 

is  no  pelvic  band  to  this  splint.  It  is  represented  in  Fig.  42, 
and  is  practically  a  combination  of  Andrews'  ischiatic 
crutch  and  Davis'  original  extension  splint. 

The  splint  just  represented  is  different  from  that  em- 
ployed by  Dr.  Hutchison,  of  Brooklyn  (Fig.  43),  in  that  the 
latter  has  a  pelvic  band,  and  a  joint  at  knee,  which  can  be 
fixed  as  desired.  Both  have  the  single  perineal  strap 
condemned  by  nearly  all  orthopedists,  and  both  are  attached 


FIG.  42. — DR.  BAUER'S  SPLINT. 


FIG.  43.— DR.  WASHBURN'S  SPILHT. 


to  the  shoe,  being  used  only  by  day.  The  weight  and  pul- 
ley are  used  by  night,  however.  Since  Dr.  Hutchison 
began  the  treatment  by  "  physiological  rest  he  does  not 
employ  splints  so  much;  in  fact,  he  says  in  his  book  his 
occupation's  [as  an  orthopedist]  gone. 

Before  proceeding  further  it  may  be  interesting  to  record 
a  few  points  concerning  extension  that  seem  to  be  settled. 

i  Traction  does  not  produce  any  appreciable  separation 
pf  the  head  9f  the  bone  from  the  acetabulum, 


DISEASES  OF  THE  HIP. 


2.  It  does  induce  fixation  and  prevents  concussion. 

3.  It  relaxes  muscles  by  overcoming  reflex  spasm. 

4.  Fixation  is  considered  of   far  more  value  than  pure 
extension. 

5.  Traction  to  be  efficacious  must  be  in  the  line  of  the 
deformity. 

Those  who  hold  most  zealously  to  the  treatment  known 
as  extension  with  motion  insist  in  the  acute  stage  on  fixa- 
tion, or  "  absolute  rest  to  the  joint," 
and  yet  all  or  nearly  all  admit  that 
it  is  quite  impossible  to  get  abso- 
lute rest  at  the  hip-joint. 

What  is  known  as  the  long  splint 
at  the  present  day  is  the  splint 
which  bears  Dr.  C.  F.  Taylor's  name. 
He  it  was  who  made  certain  modi- 
fications of  the  Davis  splint,  and 
nearly  all  who  make  modifications 
aim  to  meet  certain  indications  not 
met  by  the  Taylor  splint.  And  yet 
Dr.  Taylor  confines  himself  less 
than  do  any  of  his  followers  to  one 
form  of  splint.  In  the  Boston  Medi- 
cal and  Surgical  Journal,  for  March 
6th,  1879,  may  be  found  a  very  fair 
enunciation  of  this  gentleman's 
principles  concerning  the  "  me- 
chanical treatment  of  disease  of  the 
hip-joint."  The  two  following  pro- 
positions form  the  key-notes  to  his 
practice : 

"First.  All  organs  while  in  a 
state  of  disease  require  rest  from 
the  performance  of  their  functions 
in  the  direct  ratio  of  the  amount, 
quality,  and  intensity  of  the  abnor- 
mal movements.  Second.  What  is  rest  for  an  organ  in  one 
condition  is  not  necessarily  rest  for  it  in  another  condition; 
that  is  to  say,  an  organ,  in  a  certain  degree  of  /regressive 
inflammation,  presents  conditions  essentially  different  from 
the  same  organ  in  the  same  relative  degree  of  inflammation 
in  the  retrogressive  stage." 

What   he    understands    by    the    "so-called    mechanical 
treatment"  is  the  working  out  to  practical  conclusions  the 


FIG.  44. — DR.  HUTCHINSON'S 
SPLINT. 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.  361 


362 


DISEASES  OF  THE  HIP. 


indications  which  the  above  propositions  furnish.  He 
aims,  in  the  first  place,  to  overcome  contracted  muscles  by 
extension  and  counter-extension.  The  splint  is  applied  in 
the  line  of  deformity,  and  with  weight  and  pulley  fastened 
to  the  lower  end  of  the  splint  the  traction  is  made. 

The  patient,  however,  is  placed  on  an  inclined  plane,  with 
conveniences  for  adapting  the  angle  to  the  amount  of  re- 
laxation gained.  Fig.  44  represents  the  appliance,  splint 

and  all  save  the  weight  and  pul- 
ley. The  force  exerted  is  the  ex- 
tending power  of  the  splint  plus 
that  of  the  weight,  and  varies  ac- 
cording to  the  amount  required 
to  bring  about  relaxation — usu- 
ally from  ten  to  seventy  pounds. 
The  recumbent  posture  is  main- 
tained from  one  to  four  or  five 
weeks.  In  addition  to  the  im- 
provement in  posture  gained 
this  preliminary  treatment,  he 
claims,  "relieves  nervous  de- 
pression, gives  time  for  the  pa- 
tient to  accommodate  himself  to 
the  novel  situation,  enables  us 
to  save  the  amount  of  his  weight 
from  the  perineal  straps,  and  by 
that  amount  increase  extension 
and  hasten  the  effects  of  treat- 
ment." Fig.  45  represents  what 
is  known  in  the  shops  as  Taylor's 
splint  with  the  abduction  screw. 
It  is  not  really  the  splint  he  em- 
ploys at  present.  The  pelvic 
band  is  too  long,  and  there  will 
be  seen  other  changes  which  cor- 
respond closely  with  the  long 
splint  represented  in  Fig.  46  and 
FIG.  46.-THEMoD.FTKD  TAYLOR'S  used  by  Dr.  Taylor.  Thismodi- 
SFLINT.  fication  is  accredited  to  Mr. 

Reynders,  and  is  described  in  Dr.  Sayre's  last  edition  as 
follows : 

"  The  improved  parts  are  where  the  long  rod  is  attached 
to  the  pelvic  band.  The  long  rod  is  attached  at  A  to  a  re- 
volving plate,  B,  which  is  fastened  to  the  pelvic  band. 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   363 


When  the  plate,  B,  is  revolved  (partly),  the  long  rod  moves 
forward  and  backward.  From  the  point,  A,  the  long  rod 
moves  from  and  toward  the  other  leg,  as  shown  by  the 
dotted  lines  toward  L.  C  is  a  screw  terminating  at  D  in 
a  small  square  stem  of  steel,  fitting  to  a  key.  This  screw 
turns  in  and  out  of  the  revolving  plate,  B,  and  has  at 
the  end  of  its  thread  a  little  knob,  which  is  a  little  larger 

than  the  perforation  at  the 
upper  end  of  the  long  rod,  so 
that,  when  the  key  is  applied 
at  D,  and  turned,  the  screw, 
C,  will  force  the  long  rod  in 
the  direction  toward  L.  In 
this  manner  abduction  is 
made.  At.  F  the  long  rod  is 
divided  into  two  parts;  the 
lower  part  holds  an  endless 


FIG.  47.— THE  LONG  SPLINT  USED  BY  DR. 
SAYRB. 


FIG.  48.  —  DR.  SHAF- 
FER'S     LATERAL 

SCREW. 


screw  transversely,  which  is  worked  by  a  key,  and  rota- 
tion thus  produced."  .  . 

Dr  Shaffer  has  found  the  abduction   screw  insufficient 
for  purposes  of  adduction,  and  has  devised  a  modification, 
which   is   represented   in  Fig.  47-     This  "consists  of  two 
parts,  A  and  B,  joined  by  the  lateral  hinge,  C. 
A,  is  fastened  to  the-  pelvic  band.     The  part,  B,  is  attached 


DISEASES  OF  THE  HIP, 


to  the  shaft  of  the  splint.  Through  the  everted  lip,  D, 
there  passes  a  screw,  S,  which  operates  through  a  button 
(which  revolves  on  a  horizontal  axis),  and  which  is  fastened 
into  another  button  (also  revolving  on  a  horizontal  pivot), 
in  the  part,  A.  By  turning  the  screw,  we  can  either  ap- 
proximate the  lip,  D,  toward  the  part,  A  (producing  abduc- 
tion), or,  by  reversing  the  screw,  we  can  separate  D  from 
A,  and  adduct.  E,  E,  represent  the  screw-bolts  by  which 


\  FIGS,  49  ANB  50.— D*.  SHAFFER'S  LATERAL  SCRHW  APPLIED  TO  THE  TAYLOR  SPLINT. 

the  apparatus  is  attached  to  the  hip  band  and  shaft  of  the 
splint." 

In  using  this  "  screw  to  abduct,  the  ordinary  perineal  pads, 
which  form  the  basis  of  the  counter  extension,  will  also  be 
the  point  of  resistance.  When  we  use  the  screw  to  adduct, 
it  will  be  necessary  to  supplement  the  perineal  with  shoulder 
straps,  and  to  apply  a  little  more  extension  than  is  re- 
quired, so  that,  as  we  use  the  'lateral  screw,'  the  extra 
force  may  be  transferred  to  and  lost  upon  the  shoulder." 

Dr.  Judson  has  aimed  to  correct  certain  defects  in  the 
splint,  defects  which  many  surgeons  of  large  experience 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   365 

have  encountered.  The  principal  defect  is  this,  viz.,  "  the 
straps  which  are  fastened  to  the  adhesive  plasters  at  the 
lower  part  of  the  apparatus,  for  the  purposes  of  extension, 
become  relaxed  whenever  the  patient  assumes  the  erect 
position  and  throws  his  weight  upon  the  limb"  (Judson). 
He  argues  that  the  cause  of  this  is  due  to  a  too  lightly- 
constructed  upright,  a  pelvic  band  on  too  high  a  plane, 
and  perineal  straps  too  flexible.  The  points  are  argued  in 
detail  in  the  Medical  Gazette,  for  December  10,  1881,  and 
seem  to  be  well  taken. 

The  apparatus  used  by  him  has  a 
stronger  or  less  flexible  upright  and  pel- 
vic band  than  is  commonly  found  in  the 
long  hip  splint,  and  also  a  bolt  and  nut 
connecting  the  two  parts,  by  the  use  of 
which  they  can  be  fixed  at  any  angle 
desired  by  the  surgeon.  It  is  provided 
with  suspending  straps,  buckled  to  the 
pelvic  band  in  front  and  behind  and 
passing  over  the  shoulders,  by  which  the 
plasters  and  the  affected  limb  are  relieved 
of  the  weight  of  the  splint  in  walking. 
It  also  has  a  U-shaped  attachment,  made 
of  steel,  at  the  level  of  the  lower  part  of 
the  thigh,  by  which  motion  is  more  fully 
arrested  than  by  a  flexible  knee-pad,  as  it 
serves  to  retain  the  limb  more  closely  in  FlG  SI-_DR.  JODSON'S 

a    line     parallel   With    the   Upright    Of    the      U-SHAPED  ATTACHMENT 

FOR  BETTER  FIXATION. 

splint. 

Dr.  Taylor  does  not  use  the  abduction  screw,  but  employs 
a  different  splint  when  much  adduction  exists,  i.e.,  after  the 
preliminary  recumbent  treatment  is  completed.  The  or- 
dinary splint  is  so  modified  as  to  throw  the  weight  of  the 
body  on  the  opposite  side  of  the  pelvis,  and  is  called  the 
"jointed  supporting  splint." 

The  mode  of  applying  the  splint  is  as  follows: 
Two  strips  of  adhesive  plaster  the  entire  length  of  the 
limb,  about  four  or  five  inches  wide  at  the  upper  end  and 
one  third  that  width  at  the  lower,  are  prepared  by  cutting 
into  five  tails,  as  shown  in  Fig.  52.  From  the  centre 
tail  a  piece  from  four  to  six  inches  long  is  cut  and  added 
to  the  lower  end  for  additional  strength.  Buckles  are 
sewed  to  the  lower  end  of  these  strips,  and  the  whole  thus 
prepared  are  laid  against  the  lateral  aspects  of  the  leg, 


366 


DISEASES   OP  THE  HIP. 


the  lower  ends  beginning  about  two  inches  above  the 
malleoli.  The  centre  tails  reach  the  entire  length  of  the 
limb,  to  the  perineum  on  the  inside  and  the  trochanter  on 
the  outside.  The  lower  strips,  or,  tails,  are  wound  spirally 
about  the  leg,  extending  up  to  the  pelvis,  and  then  the 
other  two  pairs  are  wound  about  the  thigh  in  the  same 


FIG.  5*.  —  ADHESIVE  STRIP 
PREPARED  FOR  APPLICATION 
TO  LIMB. 


FIG.  53.— THB  PLASTER 
AS  APPLIED. 


manner.  This  network  of  plaster  is  represented  in  Fig. 
53.  It  will  be  seen  that  the  thigh  has  at  least  three  fourths 
of  the  attachment,  and  that  the  force  exerted  will  meet 
with  the  greatest  resistance  here.  Over  this  a  roller  is 
applied  and  the  buckled  ends  are  left  out  for  the  straps 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.  367 

at  the  lower  part  of  the  splint.  A  legging  of  twilled 
muslin  provided  with  eyelets  and  laced  up  the  inner  side 
of  the  limb  is  a  convenient  substitute  for  a  roller  band- 
age. The  stockings  have  holes  cut  through  which  the 
buckles  pass,  and  the  top  of  the  shoe  is  cut  off. 

The  pelvic  band  is  then  applied,  with  the  perineal  straps 
buckled  short  in  order  to  keep  the  band  in  a  low  plane. 
The  shaft  is  then  shortened  a  little,  and  the  tabs  are 
secured  by  the  buckles.  Traction  is  then  made  by  the 
key,  and  the  proper  adjustment  secured,  and  finally  the 
knee-pad  or  the  U-shaped  attachment  is  applied.  Fre- 
quently a  leather  strap  is  buckled  around  the  leg  and 
splint  above  the  ankle. 

Dr.  Judson  uses  traction  to  fix  the  joint  rather  than  to 
oppose  muscular  contraction,  and  is  satisfied  with  a 
moderate  degree  of  traction,  such  as  may  be  obtained  by 
two  vertical  strips  of  plaster  extending  up  the  leg  and 
thigh.  He  finds  that  the  deformity  of  the  active  stages 
of  the  disease  is  reduced  without  special  attention  by  the 
unconscious  efforts  which  the  patient  makes  during  loco- 
motion to  place  the  limb  in  a  useful  position.  He  be- 
lieves that  the  fixation  allays  inflammation,  encourages 
repair,  and  relieves  pain,  and  yet  is  not  so  inflexible  as 
to  prevent  reduction  of  deformity,  "which  takes  place 
spontaneously  while  the  patient  uses  the  perineal  straps 
as  an  ischiatic  crutch  in  locomotion."  (Judson.) 

A  high  shoe  is  worn  on  the  sound  foot,  and  very  fre- 
quently crutches  are  employed.  I  have  seen  patients  un- 
der Dr.  Taylor's  care  going  about  with  this  "  combination 
method."  Indeed,  this  name  was  given  by  Dr.  J.  A.  Wyeth 
to  a  plan  of  treatment  which  he  reported  in  the  Medical 
Gazette,  April  17,  1880.  He  combined  the  extension 
splint  with  the  "  physiological  treatment,"  and  claimed  for 
this  "combination  method"  advantages  superior  to  all 
others. 

Dr.  Sayre  uses  the  long  splint  in  larger  children,  or  when 
his  short  splint  fails  to  afford  the  necessary  protection  to 
the  joints. 

When  it  is  desirable  to  have  a  joint  at  the  knee,  and 
when  it  is  no  longer  necessary  to  immobilize  the  hip-joint  or 
take  such  precautions  against  injury — in  other  words,  dur- 
ing convalescence — Dr.  Taylor  uses  a  splint  represented  in 
Fig-  55-  "The  lower  steel  plate  is  riveted  to  the  upright, 
but  the  upper  one  is  fastened  by  three  'keepers,'  which 


DISEASES   OF  THE  HIP. 


FIG.  54. — THE  TAYLOR  SPLINT  APPLIED. 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   369 

enable  it  to  be  raised  or  lowered  in  adapting  the  instrument 
to  the  length  of  the  leg.  B  is  a  foot-piece  intended  to  rest 
under  the  foot  inside  the  shoe.  The  broad  band  of  leather 
C,  is  cut  down  at  the  top  where  there  is  a  firm  pad  F 
terminating  in  the  strap,  G,  which,  when  the  instrument  is 
applied,  fastens  in  the  buckle,  H.  The  leather,  C,  has  the 


H 


FIG.  55. 


thin  metal  plate,  E,  riveted  to  it  to  give  it  more  firmness." 
(Taylor.) 

With  the  exception  of  Mr.  Harwell's  splint,  those  I  have 
named  comprise  all  the  more  common  long  splints  now  in 
use.  The  splint  known  by  Mr.  Barwell's  name  is  not  a  pro- 
tective apparatus,  and  hence  has  not  been  employed,  so  far 
as  I  know,  in  this  country.  The  aim  with  American  sur- 
geons is  to  get  the  patient  out  of  doors.  Mr.  Thos.  Bryant, 
of  Guy's  Hospital,  has  devised  a  splint  for  maintaining  the 


370 


DISEASES  OF  THE  HIP. 


parallelism  of  the  limbs.  This,  however,  requires  that  the 
patient  shall  be  confined  to  bed.  Two  years  since  I  saw  it 
in  use  in  one  of  Mr.  Bryant's  wards,  at  Guy's,  and  this  dis- 
tinguished surgeon  pointed  out  to  me  many  advantages. 
The  patient  was  very  comfortable  and  the  limbs  were  in 
good  position.  Many  of  the  leading  English  surgeons  at 
the  present  day  speak  highly  of  the  splint  and  treatment 
advocated  by  Mr.  Hugh  Owen  Thomas. 
When  patients  must  keep  their  bed  and  none  of  these 

modes  of  making  extension 
are  at  hand,  the  prone  couch 
described  by  Mr.  Hugman 
in  his  treatise  on  Hip-Joint 
Disease,  in  1856,  affords  a  very 
simple  method  of  securing 
extension.  This  consists  of 
a  horizontal  plane  about  two 
feet  in  width,  the  length  being 
determined  by  the  patient. 
It  is  made  "  to  extend  from 
the  top  of  sternum  to  the 
bend  of  the  hip,  and  upon 
the  upper  portion  of  this  is 
placed  a  movable  chest-board 
which  slightly  elevates  the 
chest  and  shoulders,  and  the 
whole  is  covered  with  a  soft 
hair  mattress.  Depending 
from  the  horizontal  plane,  at 
an  obtuse  angle,  is  an  inclined 
plane  about  four  feet  in  length, 
covered  also  with  a  similar 
mattress,  but  divided  along 
the  centre,  so  that  one  portion 
(that  corresponding  to  the 
FIC.  s6.-D*.  wILLARD's  SPUNT.  ^ffected  side)  can  be  made  to 

extend  by  means  of  a  sliding  framework;  the  movable  por- 
tion is  furnished  with  a  padded  leathern  strap  placed  at 
its  lower  part.  The  upper  and  horizontal  part  of  the  couch 
is  supported  by  two  legs,  the  height  of  which  is  determined 
by  the  length  of  the  inclined  plane,  the  lower  end  of  which 
rests  upon  the  ground."  (Hugman,  p.  17.) 

There  are  several  short  splints,  the  best  known  of  which 
is  the  one  used  by  Dr.  Sayre,  and  the  one  in  fact  which  has 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.  3/1 


his  name.  A  splint,  however,  which  scarcely  bears  the  name 
of  an  extension  splint,  is  one  devised  by  Dr.  Willard,  of 
Philadelphia.  It  has  a  single  joint  opposite  the  articulation 
so  that  the  patient  can  sit  down  with  comfort.  It  is  rep- 
resented in  Fig.  56,  and  is  made  of  leather  over  a  cast. 
The  principle  on  which  it  is  made  and  fitted  to  the  body 
is  about  the  same  as  that  of  the 
Vance  splint,  on  page  345.  After 
it  is  moulded  and  has  thoroughly 
dried  the  pelvic  and  thigh  por- 
tions are  separated,  and  connected 
again  by  a  joint  attached  to  two 
spreading  steel  arms,  as  seen  in 
the  figure.  A  mortise,  or,  slot  is 
made  in  the  thigh  section,  and  into 
this  slot  fits  a  bolt  with  a  knob  or 
head,  by  means  of  which  it  can 
be  worked  through  one's  clothing. 
It  is  only  a  fixed  apparatus  when 
the  patient  is  standing  and  when 
the  bolt  fits  into  the  slot. 

Dr.  Willard  says  it  is  applicable 
to  a  limited  number  of  cases,  i.e., 
those  in  which  the  inflammatory 
symptoms  are  not  acute.  It  is 
always  used  in  connection  with 
crutches  and  a  high  shoe. 

The  Sayre  splint  is  applied  by 
means  of  adKesive  plaster  and 
buckles  in  very  nearly  the  same 
way  as  the  long  splint  is  applied. 
For  many  years  there  was  no 
pelvic  band  and  only  a  single 
perineal  strap.  The  present  one 
is  a  decided  improvement  on  the 
one  figured  in  Dr,  Sayre's  last 
edition.  The  one  he  now  employs 
consists  of  a  pelvic  band  partially  encircling  the  body. 
The  upright  is  attached  by  means  of  a  ball-and-socket 
joint,  and  is  divided  into  two  sections,  one  running  with 
the  other  and  controlled  by  a  ratchet  and  key.  At  the 
lower  extremity  of  this  inner  bar  are  two  projecting 
branches  going  over  to  the  inner  surface  of  the  thigh. 
Cylindrical  rollers  with  two  buckles  are  at  the  lower  en4 


FIG.  57.— DR.  SAYRE'S  SHORT 
SPLINT. 


372 


DISEASES   OF  THE   HIP. 


and  here  the  tabs  of  the  plaster  are  fastened.  My  own 
objection  to  this  short  splint  is,  that  it  does  not  sufficiently 
protect  the  joint,  and  is  not  equal  to  the  amount  of  ex- 
tension sometimes  demanded  of  a  splint.  It  is  easily  mis- 
applied, and  I  confess  that  I  am  far  more  familiar  with 
its  abuse  than  with  its  use.  Dr.  Sayre  has  borne  testimony 
himself  time  and  again  to  the  failure  on  the  part  of 
practitioners  at  home  and  abroad,  to  fully  understand  its 

application;  and  until  the  in- 
troduction of  the  pelvic  band 
and  the  two  perineal  straps  ir- 
reparable damage  to  the  joint 
could  be  done  in  a  short  time 
by  its  misapplication.  Occasion- 
ally crutches  are  used.  Noble 
Smith,  in  his  work  on  the  "  Sur- 
gery of  Deformities,"  speaks  very 
highly  of  a  short  splint  devised 
by  Mr.  E.  J.  Chance,  of  one  of 
the  London  hospitals  for  hip- 
disease.  Mr.  Chance  uses  both 
the  prone  couch  and  the  mechan- 
ical appliance.  This  appliance  is 
so  constructed  that  the  joint  can 
be  fixed  at  any  angle,  and  in  case 
of  deformity  from  muscularspasm 
the  splint  can  be  applied  to  cor- 
respond, while,  by  means  of  the 
controllable  joint,  the  deformity 
can  be  overcome  by  degrees  day 
by  day.  He  appreciates  the  im- 
portance of  fixing  the  pelvis  and 
indeed  the  spinal  column.  To 
this  end  he  employs  an  abdom- 

Fio.s8.-MR.  CHANCE'S  APPARATUS.  jnaj   band  whjch    ig  WQrn    jfl   CQn. 

junction  with  the  splint,  constructed  as  follows: 

"  A  pelvic  belt,  A,  is  adopted  below  the  iliac  crests.  An 
upright  bar,  B,  passes  from  this  belt  to  the  height  of  the 
shoulders,  and  terminates  in  a  pad.  From  this  pad  pro- 
ceed straps,  C,  forming  armlets,  or,  shoulder-straps.  From 
the  pelvic  belt  proceeds  a  stem,  D,  which  is  fixed  by  a 
leathern  casing  to  the  thigh,  and  the  stem  is  movable 
by  means  of  rack  joints,  E,  in  the  direction  of  flexion  and 
extension  as  well  as  abduction  and  adduction."  See 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   373 

Fig.  58.  Mr.  Smith  speaks  of  Mr.  Chance's  treatment,  in 
the  same  glowing  terms  that  we  Americans  are  familiar 
with.  Indeed  one  would  imagine  Mr.  Smith  giving  expres- 
sion to  an  opinion  concerning  some  one  of  the  splints  that 
are  constantly  being  devised  or  modified  in  our  own  coun- 
try. He  speaks  of  "  the  almost  immediate  relief  from 
pain  which  the  patient  experiences  when  the  splint  is  ap- 
plied; and,  above  all,  the  good  results  which  are  ultimately 
obtained  j  have  convinced  the  author  of  the  excellence  of 
Mr.  Chance's  plan  of  treating  this  disease." 


FIG.  59.— DR.  STILLMAN'S  SECTOR  SPLINT. 

Another  short  splint  combining  all  the  movements  of 
the  ball-and-socket  joint,  but  with  the  movements  under 
the  control  of  the  surgeon,  has  been  devised  by  Dr.  Chas 
F.  Stillman,  of  New  York.  At  my  request  he  has  furnished 
me  with  a  description,  a  pretty  full  abstract  of  which  I 
take  pleasure  in  inserting.  The  aim  of  the  apparatus  is 
extension  with  or  without  motion  and  at  any  desired  angle. 
It  furthermore  seeks  to  overcome  the  compensatory  lor- 
dosis.  This  apparatus  is  very  similar  in  construction  and 
design  to  the  apparatus  last  described. 

A  sector  splint  (Fig.  59)  is  placed  on  the  outer  side  of  the 


374 


DISEASES  OF  THE  HIP. 


thigh  over  the  hip,  and  is  employed  either  as  a  "  bracket"  or 
as  a  "  brace,"  the  difference  being  that  the  bracket  is  to  be 
secured  by  plaster  of  Paris  or  some  inflexible  bandage 
which  does  not  admit  of  removal,  while  the  brace  can  be 
removed  at  pleasure. 
The  sector  splint,  it  will  be  seen  from  the  figure,  is  com- 


FIG.  59.— DR.  STILLMAN'S  SPLINT  APPLIED. 

posed  of  two  plates  of  perforated  tin  that  partially  encircle 
body  and  thigh;  of  two  slotted  arms  connected  at  one  end 
by  means  of  a  clamp,  and  each  attached  at  the  other  end 
to  one  of  the  perforated  plates,  near  which  a  sharp  curve  is 
seen  to  prevent  undue  pressure  over  prominent  parts; 
and  of  a  slotted  sector  attached  to  the  slotted  arms  by  three 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.  375 

clamps.  This  sector  has  been  fully  described  by  Dr.  Still- 
man  in  the  journals,  and  further  description  in  these  pages 
is  unnecessary. 

To  apply  this  bracket,  first,  several  strips  of  moleskin 
adhesive  plaster  are  wound  tightly  around  the  thigh  just 
below  the  hip,  and  around  the  pelvis  above  the  hip.  Sec- 
ond, thigh,  pelvis,  and  waist  are  encircled  by  the  plaster-of- 
Paris  bandage,  which  is  allowed  to  partially  set.  Third, 
the  bracket  is  applied  over  this  plaster,  the  angle  being 
fixed  as  desired,  the  clamps  having  been  previously  loosened 
and  the  slotted  strips  shortened  as  much  as  possible. 
Fourth,  the  bracket  is  now  fastened  by  a  few  turns  of  the 
plaster  bandage,  and  this  is  covered  by  a  dry  muslin  roller 
to  ensure  cleanliness.  When  the  plaster  is  set  the  whole 
constitutes  the  splint,  and  is  represented  in  Fig.  59. 
Enough  precautions  have  been  taken  to  secure  the  desired 
amount  of  firmness,  and  the  apparatus  extends  from  axilla 
to  knee,  the  underlying  adhesive  plaster  preventing  any 
slipping  or  sliding  on  thigh  or  trunk. 

To  make  extension  the  slotted  strips  are  pushed  away 
from  the  centre,  thus  increasing  the  distance  between  body 
and  thigh  attachments.  The  degree  of  extension  gained 
is  secured  by  the  clamps  on  the  slots. 

By  means  of  the  clamps  on  the  sector  fixation  may  be 
secured,  or  motion  may  be  allowed  and  extension  be  main- 
tained at  the  same  time.  Dr.  Stillman  combines  this  plan 
with  the  crutches  and  high  shoe.  The  advantages  he  claims 
for  his  splint  are:  i.  Local  extension  of  the  joint  diseased; 
2.  Fixation  at  any  angle  with  or  without  extension;  3. 
Motion  with  or  without  extension;  4.  Gradual  reduction 
of  the  flexion;  5.  Opportunity  for  local  inspection  and 
topical  applications. 

When  a  brace  is  desirable — and,  by  reason  of  the  unclean- 
liness  of  plaster,  it  is  desirable  to  do  away  with  this  mode 
of  application  whenever  anything  different  can  be  afforded 
— a  removable  apparatus  has  been  constructed  by  Dr.  Still- 
man, and  is  represented  both  in  back  and  side  views  in 
Fig.  6 1.  The  back  frame  here  represented  is  provided  with 
abduction,  rotation,  and  flexion  clamps  for  overcoming  the 
obliquity  of  the  pelvis.  A  rotation  joint  on  the  side  of  the 
brace  below  the  hip  is  also  provided  for  the  correction  of 
inward  and  outward  rotation. 

The  apparatus  is  attached  to  the  thigh  and  trunk  in  the 
usual  manner  by  straps  and  girths,  and  if  additional 


DISEASES   OF   THE   HIP. 


extension  is  desired  a  perineal  strap  is  attached  above  and 
an  adhesive  plaster  noose  below  the  joint  is  added. 

Still  another  short  splint  is  used  by  Dr.  M.  Josiah 
Roberts,  who  has  kindly  placed  a  description  of  the  same 
at  my  disposal. 


FIG.  61. — DR.  STILLMAN'S  BRACE  FOR  HIP  AND  PELVIC  DEFORMITY. 

The  instrument  consists  of  a  pelvic  and  a  femoral  seg- 
ment. The  former  is  made  of  very  thin  sheet  steel  covered 
with  leather  on  the  outside  and  thoroughly  upholstered  on 
the  inside.  It  is  broad,  and  to  secure  a  good  fit  he  moulds 
it  over  a  plaster  cast  of  the  patient's  pelvis.  The  latter 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.  377 

(the  femoral  segment)  is  composed  of  two  compound 
side-bars,  which  extend  down  along  the  thigh  upon  the 
inner  and  outer  aspects,  and  are  constructed  with  special 
reference  to  exerting  continuous  elastic  linear  traction  upon 
the  thigh.  The  mechanism  by  means  of  which  this  is  ac- 
complished can  be  understood  by  reference  to  Fig.  62. 
Two  side-bars  are  here  represented;  one  is  provided  with 
expanded  margins  which  have  been  turned  over  so  as  to 
perform  a  shell  through  which  the  other  slides.  The  upper 
or  proximal  end  of  the  shell  is  converted  into  a  rectangular 
loop  which  completely  closes  over  the  sliding  bar,  ,:-••'., 
and  upon  this  a  brass  pin,  A,  is  soldered. 

The  lower  or  distal  end  of  the  sliding  bar  is  |°j 
likewise  provided  with  a  brass  pin,  B.  Any  force 
which  brings  these  two  pins  nearer  together 
must  of  necessity  lengthen  the  instrument,  as 
shown  by  the  dotted  line  in  the  figure.  It  must 
also  as  a  consequence  exert  a  traction  force  upon 
the  limb  to  which  it  is  attached.  In  order  to  make 
this  traction  force  elastic,  or,  in  other  words,  like 
manual  traction  a  narrow  strip  of  strong  elastic 
webbing  provided  at  one  end  with  a  buttonhole  is 
slipped  over  the  brass  pin  at  A.  To  the  pin  B, 
which  is  screwed  into  the  opposing  end  'of  the 
other  bar  a  buckle  is  attached. 

The  instrument  having  been  applied  and  screwed 
into  position,  with  the  brass  pins  at  the  greatest 
possible  distance  apart,  we  can  by  means  of  this 
strip  of  webbing  and  the  buckle  exert  any  desired 
amount  of  elastic  force.  By  doing  this  the  op- 
posing ends  of  the  two  bars  are  approximated 
and  the  instrument  is  thus  lengthened.  It  is  in  this 
way  that  the  traction  force  is  graduated.  By  substituting  a 
non-elastic  strip  for  the  elastic  one  fixed  or  rigid  traction 
could  be  maintained  by  the  same  mechanism.  The  distal 
ends  of  the  side  bars  are  fixed  to  a  metallic  band  which  en- 
circles the  limb  just  above  the  knee.  This  band  is  secured 
in  position  by  means  of  strips  of  strong  adhesive  plaster 
placed  longitudinally  around  the  thigh  with  their  lower 
ends  turned  up  over  it  (the  band)  and  retained  in  position 
with  a  roller  bandage.  The  lower  ring  is  thus  prevented 
from  being  pushed  down  over  the  knee  when  traction  is 
made  as  above  described. 

At  X  (Fig.  63)  a  simple  hinge-joint  connects  the  outer  side 


378 


DISEASES  OF  THE  HIP. 


Fia.  63.— DR.  ROBERTS'S  SPLINT. 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   379 

bar  with  the  pelvic  segment.  A  like  joint  is  found  at  the  prox- 
imal end  of  the  inner  side  bar  at  its  junction  with  the  peri- 
nea.1  strap.  These  two  joints  permit,  it  is  claimed,  articular 
action  at  the  hip  during  locomotion  and  in  changing  from 
the  sitting  to  the  standing  posture  or  the  reverse.  By  con- 
tinuously exerting  elastic  traction,  it  is  further  claimed,  artic- 
ular motion  becomes  possible  without  inter-articular  pres- 
sure or  friction,  and  without  giving  rise  to  the  slightest  dis- 
comfort to  the  patient. 

Under  these  circumstances  Dr.  Roberts  thinks  it  is  evi- 
dent that  the  condition  of  the  joint  more  nearly  approxi- 
mates that  which  we  find  in  health  than  it  would  were  it 
fixed.  The  Doctor  argues  that  in  this  way  we  avoid  the 
depreciating  influences  which  prolonged  immobilization  of 
an  articulation  necessarily  has  on  the  local  nutrition,  that 
the  circulation  through  the  limb  is  facilitated,  that  we  get 
the  maximum  amount  of  nutrition  in  the  joint  through  the 
agency  of  which  a  favorable  temperature  is  sustained  for  the 
growth  and  development  of  adjacent  parts,  and  that  repair 
in  decayed  tissues  can  the  more  readily  be  promoted. 

Passing  over  the  joint  anteriorly  at  X  is  a  semicircular 
rod  upon  which  a  coiled  steel  spring  is  placed,  the  action  of 
which  is  to  oppose  flexion  of  the  thigh  on  the  abdomen. 
An  adjustable  nut  on  the  curved  rod  furnishes  the  surgeon 
with  the  means  of  exercising  his  discretion  as  to  how  much 
motion  at  the  joint  shall  be  permitted. 

The  splint  as  applied  is  represented  in  Fig.  63,  and  it 
will  be  seen  that  no  other  joints  save  the  one  diseased 
are  restricted  in  their  normal  movements.  The  sustaining 
power  of  this  apparatus  lies  in  its  elastic  attachments,  and 
not  in  the  steel  bars  which  compose  the  framework.  The 
office  of  these  bars  is  only  to  give  direction  to  the  force  ex- 
erted by  the  elastic  side-straps.  This  principle  enables  the 
Doctor  to  construct  the  splint  of  such  light  material  that  it 
is  easily  portable  and  equally  durable  with  the  heavier  iron 
and  steel  appliances.  Another  advantage  he  claims  is  that 
it  does  not  interfere  with  the  impact  of  the  foot  upon  the 
ground  during  locomotion,  thus  preserving  the  foot  sense, 
which  is  of  the  greatest  possible  advantage  to  the  patient 
in  averting  sudden  jars  and  traumatisms.  To  still  fur- 
ther reduce  the  effect  of  jar  incident  to  locomotion  he 
has  his  patients  wear  soft  rubber  heels  in  their  shoes. 

To  recapitulate  the  advantages  claimed  by  its  author  for 
this  splint. 


380  DISEASES  OF  THE  HIP. 

1.  It  protects  diseased  areas  from  traumatism. 

2.  It  furnishes  sufficient  artificial  support  to  counterbal- 
ance the  loss  of  power  on  the  part  of  the  affected  member. 

3.  It  places  the  movements  of  the  diseased  articulation 
absolutely  under  the  control  of  the  surgeon  at  all  times. 

4.  It  permits  inter-articular  pressure. 

5.  By  its  use  we  can  maintain  the  general  and  local  nu- 
trition at  the  highest  possible  standard  for  the  purposes  of 
carrying  on  the  repair  of  the  diseased  tissues. 

6.  The  nullification  of  reflex  muscular  spasm. 

7.  Its  easy  portability. 

8.  Its  non-interference  with  the  performance  of  the  func- 
tions of  healthy  joints. 

I  have  given  at  some  length  many  of  the  forms  of  appa- 
ratus now  in  use,  their  construction  and  their  claims,  and 
with  so  many  in  vogue  one  wonders  why  it  is  that  we  have 
any  imperfect  cures  in  our  midst.  The  fact  remains,  how- 
ever, that  children  do  get  well  with  stiff  and  deformed 
joints,  that  many  are  subjected  to  various  operations,  and 
that  many  die  of  the  disease,  notwithstanding  they  have 
been  subjected  to  both  the  mechanical  and  the  expectant 
treatment.  It  is  also  a  significant  fact  that  go  where  you 
will  some  one  tells  you  of  a  friend  or  an  acquaintance  who 
has  had  "  hip-disease,"  and  when  you  begin  to  inquire 
about  the  result,  you  will  hear  of  a  short  limb,  a  stiff 
joint,  or  an  enfeebled  constitution.  You  will  hear  further- 
more that  the  patient  was  under  Dr.  A's  care  or  Dr.  B's 
care  a  number  of  years,  but  that  Dr.  C  or  Dr.  D  had  the 
patient  first  and  this  accounts  for  the  result. 

I  am  well  aware  that  patients  are  neglectful,  that  they  tire 
of  this  treatment  or  of  that,  and  that  they  fall  into  the  hands 
of  charlatans  both  in  and  out  of  the  profession.  Still  my 
claim  is  that  we  should  know  of  more  of  those  fine  results 
claimed.  In  other  branches  of  medicine  men  publish  results 
of  cases,  publish  statistics  of  cures,  and  yet  one  has  to  look 
through  a  vast  field  of  orthopedic  literature  to  find  good 
cases,  and  when  he  does  find  them  they  are  often  so  im- 
perfectly recorded  as  to  be  unfit  for  statistical  purposes. 
What  then  does  the  treatment  of  chronic  articular  ostitis 
of  the  hip  by  splints  accomplish? 

In  the  paper  of  Dr.  Taylor's  from  which  I  have  already 
quoted  there  occur  some  representative  cases.  One  was  in 
a  boy  four  years  of  age  who  had  a  slight  halt  in  his  right 
leg.  A  history  of  a  traumatism  was  obtained,  and  the  first 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   381 

exacerbation  followed  immediately  on  the  accident.  This 
subsided,  and  Dr.  Taylor  saw  him  some  weeks  afterward. 
The  difference  in  the  motion  of  the  two  joints  was  very 
slight.  The  case  did  not  come  under  treatment,  and  three 
months  later  another  exacerbation  more  severe  than  the 
first  came  on,  and  the  Doctor  was  again  consulted.  Treat- 
ment was  again  postponed  by  the  parents.  The  case  was 
at  that  time  advancing  into  the  second  stage.  Three  months 
later  abscess  had  appeared,  and  the  patient  was  harassed  by 
another  exacerbation  still  more  acute  and  still  more  persist- 
ent. At  this  time  the  deformity  in  flexion  was  very  great. 
Treatment  was  now  accepted,  the  splint  was  applied,  the 
recumbent  position  was  assumed,  and  the  weight  and  pulley 
were  attached  to  the  distal  end  of  the  splint  over  the  inclined 
plane.  The  extension  force  employed  was  thirteen  pounds. 
This  stage  of  the  treatment  was  persevered  in  for  three 
months,  the  abscess  being  opened  in  the  meanwhile  and 
discharging  copiously  for  two  months. 

On  leaving  the  bed  the  joint  was  well  protected  by  the 
splint,  and  traction  both  day  and  night  maintained.  During 
the  next  five  months  the  long  splint  was  worn,  the  sinuses 
caused  very  little  discomfort,  the  limb  was  held  in  good 
position,  there  was  a  tolerable  mobility  of  the  joint,  and  the 
general  health  of  the  patient  was  very  good.  Later  the 
"joint-supporting"  splint  was  applied,  say  twelve  months 
after  treatment  was  begun.  At  the  end  of  another  twelve 
months  he  was  discharged  cured,  and  the  report  reads:  "  He 
does  not  limp.  There  is  a  slight  difference  in  the  lengths  of 
the  lower  extremities,  but  not  enough  to  be  noticeable  in 
his  locomotion.  He  is  directed  to  return  frequently  during 
the  next  two  years  for  examination." 

Another  case  is  reported.  This  was  in  a  girl  seven  years 
of  age  who  had  manifested  the  first  signs  of  a  bony  lesion 
at  the  hip  some  nineteen  months  before  coming  under  Dr. 
Taylor's  care.  The  treatment  during  fifteen  months  of  this 
time  had  been  by  weight  and  pulley,  and  there  was  no  pain 
from  the  beginning  nor  any  during  the  whole  time  she  was 
confined  to  the  bed.  Her  general  health  too  had  continued 
good  during  this  long  period  of«confinement.  The  deformity 
was  very  slight,  yet  there  was  limited  movement  at  the 
joint.  It  required  two  weeks  in  bed  with  the  extension 
splint  to  completely  relax  the  muscles.  Then  the  long 
splint  was  worn  ten  months,  when  the  patient  was  discharged 
perfectly  restored.  Two  years  later  he  examined  the  girl, 


382  DISEASES  OF  THE  HIP. 

finding  that  "  the  child  has  been  going  about  like  other  chil- 
dren; there  is  perfect  motion  at  the  affected  joint,  and  no 
discoverable  difference  between  the  affected  joints,  and  no 
discoverable  difference  between  the  functions  of  the  two 
limbs.  Both  trochanters  are  on  the  same  level." 

Still  another  case  is  reported  with  an  equally  good  result. 
I  have  now  under  observation  a  case  that  came  under  the 
same  treatment  about  eight  years  ago  with  such  a  deformity 
as  the  first  one  reported  had.  It  seemed  to  have  been  a 
genuine  case  of  bone  disease  that  had  not  yet  resulted  in 
abscess.  This  patient  had  eight  years  of  faithful  treatment, 
going  through  all  the  stages  of  the  same,  and  to-day  the 
hip  is  stiff,  the  angle  of  deformity  is  about  150°,  there  is  one 
inch  real  and  two  and  a  quarter  inches  practical  shortening, 
and  the  case  would  not  make  a  good  one  by  which  to  illus- 
trate any  special  form  of  treatment. 

The  following  statistics  from  Dr.  Taylor's  papers  are  in- 
teresting, and  I  incorporate  his  report  with  much  pleasure: 

"  Leaving  out  of  consideration  all  cases  whose  histories, 
subsequently  to  their  treatment,  are  unknown  or  in  doubt, 
I  find  that  there  remain  ninety-four  private  cases  of  hip- 
joint  disease  which  were  under  personal  observation  and 
continuous  treatment  from  the  time  they  applied  until  they 
died  or  were  cured,  and  whose  present  condition  is  now,  or 
was  very  recently,  a  matter  of  personal  knowledge,  for  no 
case  whose  ultimate  fate  is  not  positively  known  deserves  a 
moment's  consideration  in  any  estimate  of  the  probable 
value  of  treatment  for  the  hip-joint.  Of  the  ninety-four 
cases  three  died, — two  of  the  disease,  and  one  was  run  over 
and  killed.  Among  them  there  were  twenty-four  with 
suppurating  joints  and  discharging  abscesses, — nearly  all 
in  that  condition  when  first  applying.  Of  these  twenty- 
four  with  abscesses,  two  died, — the  same  as  stated  above, — 
and  in  five  the  discharge  has  not  yet  ceased.  Deducting 
these  seven,  there  remain  seventeen  fully  recovered,  or 
seventy  per  cent  of  the  suppurating  cases.  Three  of  the 
seventeen  recovered  cases  have  ankylosis,  and  fourteen  re- 
covered with  practicable  joints — the  majority  with  ample 
and  some  with  perfect  motion.  The  ratio  of  motion  to 
ankylosis,  in  the  cases  recovering  after  suppuration  more 
or  less  extensive,  is  as  eighty-two  to  eighteen.  In  two  of 
the  cases  still  discharging  ankylosis  is  progressing  favor- 
ably, and  in  three  there  is  excellent  motion,  and,  except  for 
the  slight  discharge  remaining,  they  would  be  among  our 


TREATMENT  OK  CHRONIC  ARTICULAR  OSTITIS.  383 

best  cases.  The  joint  motions  are  nearly  perfect,  and  the 
joints  themselves  are  apparently  well,  the  present  discharge 
being  supported  undoubtedly,  as  it  so  often  is,  by  eccentric 
periosteal  excoriations.  In  such  cases  nothing  so  tends 
toward  recovery  as  the  action  of  the  muscles  contiguous  to 
such  eccentric  implantations. 

"  The  above  enumeration  includes  all  cases  of  the  class 
previously  specified  for  the  nine  years  preceding  Novem- 
ber, 1877,  but  excludes  the  cases  received  since  that  date." 

In  view  of  the  fact  that  the  term  hip-joint  disease  with 
Dr.  Taylor  is  not  synonymous  with  chronic  articular  ostitis 
of  the  hip,  these  statistics  are  not  as  valuable  as  they  might 
be  if  only  cases  of  true  bone  disease  were  embraced  in  these 
ninety-four  private  patients. 

During  the  past  year  I  have,  through  Dr.  Judson's  kind- 
ness, had  an  opportunity  of  examining  with  him  three  pa- 
tients whose  cases  he  reported  in  the  Illustrated  Quarterly 
of  Medicine  and  Surgery,  No.  2,  1882.  The  cases  are,  I 
think,  classical  in  the  literature  of  mechanical  surgery,  and 
I  feel  justified  in  reproducing  them,  in  abstract,  in  these 
pages. 

No.  i  was  a  boy  aged  six,  and  presented,  when  Dr.  Judson 
saw  him,  an  enormous  abscess  with  all  the  usual  signs  of  the 
third  stage  of  the  disease,  which  was  of  nineteen  months  du- 
ration. The  abscess  opened  spontaneously  the  same  day  on 
which  he  was  examined.  The  general  condition  was  bad,  the 
limb  was  strongly  flexed  and  adducted,  and  the  slightest  at- 
tempts at  motion  elicited  screams  of  pain.  It  was  found  that 
the  same  case  had  come  under  my  own  observation  only  a 
month  before  the  above  notes  were  made,  and  in  my  rec- 
ords I  find  my  own  notes  corresponding  very  closely  with 
Dr.  Judson's.  I  find  also  this  significant  remark,  that  the 
boy  had  been  under  the  splint  treatment  for  twelve  months 
by  a  distinguished  orthopedic  surgeon,  in  conjunction  with 
the  family  physician,  and  that  the  parents  were  very  much 
dissatisfied  with  the  combination. 

Six  days  after  Dr.  Judson  saw  the  case  the  long  splint  of 
Dr.  Taylor's  was  applied  and  the  patient  was  about  the 
house  daily  from  the  very  beginning  of  treatment.  The  de- 
formity disappeared  in  due  course  of  time.  The  progress 
was  slow,  abscess  followed  abscess,  until  finally  there  were 
nine  sinuses  about  the  joint,  all  leading  to  carious  bone.  Five 
extended  in  a  line  down  the  outer  side  of  the  thigh  from  the 
trochanter  to  the  middle  third  of  the  thigh,  and  from  one  of 


384  DISEASES  OF  THE  HIP. 

these  a  fragment  of  bone  extended.  There  were  well-marked 
exacerbations  from  time  to  time,  but  these  were  not  of  a 
very  painful  nature.  Some  of  the  sinuses  closed  in  time, 
the  adhesive  straps  were  finally  removed,  and  for  several 
months  the  splint  was  suspended  from  the  shoulder  and  he 
walked  upon  an  ischiatic  crutch.  An  elevated  shoe  on  the 
sound  limb  was  worn  all  the  while. 

He  was  under  treatment  two  years  and  five  months,  and 
his  condition  six  months  later  was  as  follows:  "The  limb 
is  in  good  position,  neither  abducted  noradducted,  and  flexed 
at  a  slight  angle  sufficient  to  allow  him  to  sit  comfortably, 
and  yet  not  to  interfere  with  locomotion.  The  motions  of 
the  knee  are  perfect.  He  walks  with  firmness,  runs  rapidly, 
and  never  uses  a  cane  ....  an  inch  of  shortening  .... 

absence  of  motion  at  the  joint The  cicatrices  are 

firm,  deeply  depressed,  and  in  some  instances  attached  to 
the  bone  beneath." 

Three  years  and  six  months  afterward  his  condition  was 
reported: 

A  point  of  moisture  simply,  at  the  upper  end  of  scar  over 
tuberosity  of  ischium  ;  atrophy  of  thigh,  two  and  three- 
quarter  inches  ;  of  knee,  three-quarters  of  an  inch  ;  of  calf, 
only  a  half-inch. 

The  position  of  the  limb  was  150°  in  flexion  and  about 
15°  in  adduction.  The  real  shortening  was  one  and  a 
quarter  inches,  the  practical,  two  and  a  half  inches,  with 
no  attempt  at  arranging  the  limbs  symmetrically.  The 
knees  were  equally  flexible. 

No.  2  was  a  girl  three  years  of  age,  with  a  tuberculous 
family  history.  The  disease  involved  the  right  hip,  and 
had  existed  at  least  one  year.  An  immovable  dressing  of 
plaster  of  Paris  and  subsequently  a  long  splint  with  a  sin- 
gle perineal  strap  and  applied  without  adhesive  plaster, 
had  been  her  previous  treatment.  When  the  patient  came 
under  treatment  at  the  hands  of  Dr.  Judson  there  was 
marked  adduction  and  flexion  of  the  thigh,  characteristic 
of  the  third  stage.  For  several  weeks  previously  she  had 
suffered  from  intense  pain  and  suppuration  was  suspected. 
The  treatment  was  the  same  as  in  No.  i.  The  pain  soon 
abated,  the  position  of  the  limb  improved,  adduction  giving 
place  to  abduction  and  the  flexion  being  materially  dimin- 
ished. Abscess  formed,  nevertheless,  and  was  opened  five 
months  after  the  beginning  of  treatment.  The  sinus  was 
followed  in  the  ensuing  eighteen  months  by  five  others, 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.   385 

variously  located  about  the  joint,  and  the  pus  secreted  was 
abundant  and  offensive.  The  mechanical  treatment  was 
supplemented  by  cod-liver  oil,  wines,  and  chalybeates. 
Exacerbation  marked  the  approach  of  new  abscesses,  and 
some  were  noted  for  their  high  febrile  reaction  and  emacia- 
tion, threatening  a  fatal  termination.  Mechanical  treatment 
was  continued  for  two  years  and  seven  months.  Strong 
traction  was  used  during  the  first  half  of  that  time,  and 
during  the  latter  half  the  apparatus  was  applied  more 
loosely,  and  for  several  months  it  was  worn  only  in  the  day- 
time, as  an  ischiatic  crutch  merely. 

Eight  months  after  the  removal  of  the  splint  her  condi- 
tion was  reported  as  follows: 

Her  health  is  perfect,  and  she  is  able  to  walk  and  run 
without  assistance  of  any  kind.  The  position  of  the  femur 
is  favorable  both  for  walking  and  sitting,  there  being  no 
abduction  or  adduction,  but  a  moderate  degree  of  flexion, 
and  the  shortening  is  only  one  fourth  of  an  inch,  evidently 
due  to  a  diminution  in  all  the  measurements  of  the  limb. 
When  she  walks  slowly  it  is  difficult  to  perceive  any  limp- 
ing, although  the  motions  of  the  joint  itself  are  so  slight  as 
to  be  of  very  little  if  any  advantage  in  locomotion. 

It  was  two  years  and  four  months  after  the  above  note 
was  made  that  I  saw  the  child  with  Dr.  Judson,  and  we 
found  her  still  in  good  health  and  very  active.  Her  short- 
ening as  measured  from  the  umbilicus  with  no  attempt 
at  symmetry  was  one  and  a  half  inches  ;  measured  from  the 
anterior-superior  spinous  processes  it  was  a  half-inch 
without,  and  a  quarter  of  an  inch  with,  an  attempt  to  place 
the  limbs  symmetrically.  We  could  not  detect  any  motion 
at  the  hip,  and  her  angle  of  deformity  was  160°  in  flexion, 
with  about  5°  in  adduction.  She  was  not  able  to  button 
and  unbutton  her  shoes  in  the  natural  way. 

No.  3  was  a  boy  who  was  seven  years  old  at  the  time  he 
came  under  treatment,  and  had  suffered  from  the  disease 
for  four  years.  He  had  worn  a  light  hip  splint,  and  to  this 
Dr.  Judson  attributed  his  lack  of  progress.  The  reporter 
states  that  the  usual  signs  of  the  third  stage  were  present, 
without  stating  the  degree  of  the  deformity  and  the  con- 
sequent inconvenience  in  locomotion.  An  abscess  was, 
however,  already  recognizable.  He  had  the  same  line  of 
treatment  as  was  adopted  in  the  two  cases  just  reported. 
Suppuration  progressed,  however,  and  finally,  after  great 
distension  of  the  parts,  four  sinuses  were  established,  one  of 


386  DISEASES  OF  THE  HIP. 

which  was  in  the  groin  and  one  above  Poupart's  ligament. 
"The  severity  and  persistence  of  the  symptoms,  the  num- 
ber and  position  of  the  sinuses,  the  long  continuance  and 
often  offensive  nature  of  the  discharge,  and  the  character 
of  the  resulting  cicavlices,  of  which  two  are  attached  to  the 
bone,  clearly  show  that  the  case  was  one  of  destructive 
ostitis  and  disorganization  of  the  joint."  And  such  was  his 
history.  At  the  end  of  a  year  repair  began,  and  the  fix- 
ation of  the  joint  was  no  longer  necessary.  Up  to  this 
time  he  had  persisted  in  the  use  of  crutches.  These  were 
now  laid  aside,  but  the  splint  was  worn  for  three  years 
longer.  Eighteen  months  after  all  treatment  was  dis- 
continued he  was  an  active  robust  boy,  taking  long  walks 
to  and  from  school,  was  a  good  skater,  and  when  he  walked 
slowly  there  was  no  perceptible  defect  in  his  gait.  There 
was  a  half-inch  shortening,  limb  was  in  good  position,  /.<?., 
the  angle  at  a  useful  degree  of  flexion,  and  there  was  no 
motion  at  the  joint. 

Three  years  after  the  above  condition  was  found  I  examin- 
ed him  with  Dr.  Judson,  and  we  found  the  boy  still  as  active 
and  still  as  healthy.  There  was  a  shortening  of  one  and  a 
quarter  inches  as  measured  from  the  umbilicus  (practical 
shortening),  and  an  actual  lengthening  of  a  half-inch  as  meas- 
sured  from  the  anterior-superior  spinous  process,  with  the 
limbs  symmetrically  placed.  There  was  an  arc  of  motion  of 
at  least  10°  in  flexion,  and  a  slight  amount  of  abduction,  ad- 
duction, and  rotation  was  possible.  The  trochanter  was 
not  above  Nelaton's  line. 

Now  these  cases  are  very  instructive,  and  they  were  re- 
ported just  as  they  were.  I  have  notes  of  many  that  are 
now  under  the  long-splint  treatment,  and  while  they  are 
not  ready  for  a  final  report  I  can  at  least  report  progress. 
All  are  comfortable,  in  all  the  limbs  are  in  good  position, 
and  all  are  out  of  doors  most  of  the  time. 

I  have  notes  of  a  few  that  have  been  under  the  short-splint 
treatment,  and  nearly  all  have  done  badly.  Two  that  I 
now  recall  went  on  to  distressing  deformity. 

From  a  study,  then,  of  the  mechanical  treatment  of  this 
disease,  I  am  persuaded  that 

1.  The    short    extension    splints  which   permit   motion 
exert  very  little  if  any  influence  on  the   average  case  of 
chronic  articular  ostitis  of  the  hip. 

2.  The  long   splint  in  competent  hands  secures  for  us 
better  results  than  does  any  of  the  splints  in  general  use. 


TREATMENT  OF  CHRONIC  ARTICULAR  OSTITIS.  387 

3.  It  is  better  to  combine  the  extension  splint  with  the 
crutches  and  high  shoe. 

4.  An  intelligent  use  of  the  splint  is  but  a  very  import- 
ant part  of  a  true  expectant  treatment. 

I  am  indebted  to  Dr.  Judson's  paper  for  the  following: 
"  If  we  recall  the  morbid  anatomy  of  this  disease,  in  which 
the  integrity  of  the  central  portion  of  the  bone  is  invariably 
assailed,  we  can  better  understand  the  comparison  of  hip- 
disease  to  a  fracture  of  the  bone,  and  the  more  readily 
recognize  the  propriety  of  treating  it  by  fixation.  If  hip- 
disease  were  synovitis,  invading,  under  the  pressure  of  re- 
flex muscular  contraction,  first  the  cartilage  and  then  the 
bony  tissue,  it  would  be  right  to  try  to  diminish  this  pres- 
sure by  traction,  or  any  other  method  believed  to  be  prac- 
ticable. We  might  even  attempt  the  difficult  combination 
of  traction  with  mobility,  in  the  hope  that  motion  without 
friction  would  perhaps  assist  the  process  of  repair  and 
secure  a  recovery  without  impairment  of  mobility.  But 
the  disease  is  not  synovitis.  It  is  ostitis,  beginning  in  the 
cancellous  tissue,  or  at  the  epiphysal  junction,  excavating 
the  bone,  undermining  its  strength,  progressing  from  with- 
in outward,  and  involving  in  time  all  the  structures  of  the 
joint.  In  this  view  it  is  clear  that  the  proper  local  treat- 
ment is  protection  from  the  pressure  and  concussion  in- 
cident to  walking,  and  the  prevention  of  motion  in  the 
joint.  As  in  a  fracture,  so  in  hip-disease,  the  part  should 
be  placed  in  a  favorable  position  for  the  action  of  the 
natural  reparative  processes  which,  aided  by  appropriate 
general  treatment,  are,  as  a  rule,  able  to  limit  this  morbid 
process  when  it  occurs  in  parts  which,  like  the  ankle,  are 
more  easily  protected  from  disturbance  and  violence  by  the 
voluntary  efforts  of  the  patient," 


CHAPTER  XVIII. 
OPERATIVE  TREATMENT  IN  CHRONIC  ARTICULAR  OSTITIS. 

For  the  arrest  of  disease  in  its  incipiency  surgery  is  not 
to  be  credited  with  any  brilliant  results.  It  has  often  oc- 
curred to  me  that  much  might  be  done  by  the  judicious 
use  of  the  drill.  This  instrument  has  not  been  used  to  any 
great  extent  in  this  country,  i.e.,  I  am  not  familiar  with  any 
cases  published  in  which  it  has  been  employed.  If  one 
can  feel  reasonably  sure  that  the  disease  is  confined  to  the 
femur,  then  the  joint  might  be  saved  by  establishing  a 
drainage  on  the  distal  side  of  the  capsular  ligament.  The 
question  forces  itself  on  one,  whether  even  this  procedure 
would  prevent  the  extension  of  the  lesion  by  contiguity  to 
the  articular  surfaces. 

I  was  aware  that  Mr.  Macnamara  had  drilled  the  head 
and  neck  of  the  femur  in  cases  of  serous  synovitis  of  the 
hip,  and  in  a  conversation  with  this  surgeon  some  two 
years  ago  I  learned  that  he  had  also  employed  this  treat- 
ment in  chronic  articular  ostitis  of  the  hip.  The  results  in 
his  synovitic  cases  were  very  encouraging,  and  are  recorded 
in  his  "  Diseases  of  the  Joints."  Recently  I  received  from 
him  a  summary  of  the  cases  treated,  and  I  take  pleasure  in 
giving  the  substance  of  his  communication. 

During  the  three  years  ending  in  1882,  he  had  drilled  the 
trochanter  neck  and  head  of  the  femur  twenty-seven  times 
for  the  relief  of  "hip-joint  disease,"  and  of  this  number  he 
is  convinced  that  twenty-four  have  made  good  recoveries. 
"  Several,"  he  says,  "  have  grown  up  into  strong  healthy 
children  with  an  amount  of  compensatory  movement  in  the 
spine  which  enables  them  to  go  about  like  other  healthy 
children."  One  case,  a  girl  aged  twelve  years,  died  three 
months  after  the  operation,  and  it  was  found  that  the  drill 
had  passed  into  the  middle  of  the  head  of  the  bone,  and 
not  into  the  joint.  The  passage  taken  by  the  instrument, 
was  filled  with  a  comparatively  soft  fibre-cellular  substance 
with  islands  of  cartilage  in  which  calcification  of  the  car- 
tilage was  in  progress.  A  layer  of  newly-formed  articular 


TREATMENT   IN   CHRONIC  ARTICULAR   OSTITIS.    389 

cartilage  covered  the  head  of  the  femur,  and  a  very  thin 
layer  of  what  seemed  to  be  the  original  articular  cartilage 
lay  loose  in  the  joint. 

In  two  other  cases  of  the  twenty- seven,  at  periods  vary- 
ing from  four  to  seven  months,  the  disease  was  not  checked 
by  the  operation,  and  he  was  compelled  to  excise  the  head 
of  the  femur. 

His  conclusion  is  that  he  does  not  now  think  drilling 
should  be  performed  for  osteo-myelitis  in  this  locality 
until  other  treatment  has  failed.  His  management  of  a 
case  at  present  is  this: 

When  it  is  clear  that  well-marked  symptoms  have  de- 
veloped the  patient  is  put  under  the  care  of  an  experienced 
nurse  in  such  a  locality  that  the  best  possible  hygiene  can 
be  maintained,  plenty  of  fresh  air  and  light,  proper  food, 
principally  fresh  milk.  At  night  the  limb  is  secured  by 
weight  and  pulley,  and  by  day  a  Thomas  splint  is  applied, 
while  the  child  is  encouraged  to  go  about  as  much  as  pos- 
sible, aided  by  crutches  and  high  shoe.  If,  at  the  end  of 
from  four  to  six  months  no  improvement  follows  this  treat- 
ment, he  resorts  to  the  drill,  dividing  at  the  same  time 
the  adductor  muscles,  and  it  may  be  the  tensor  vaginae 
femoris.  A  modified  Bryant's  splint  is  applied  immedi- 
ately after  the  operation,  and  secured  to  both  limbs  and 
pelvis  by  means  of  plaster-of-Paris  bandages.  No  exten- 
sion or  traction  is  made,  the  necessity  for  this  being  obvi- 
ated by  the  division  of  the  muscles. 

I  have  thus  been  explicit  in  the  details  of  the  treatment 
employed  by  Mr.  Macnamara,  because  I  believe  him  to  com- 
bine very  happily  the  conservative  and  the  advanced  surgical 
ideas  of  our  British  cousins.  The  question,  as  I  remarked 
before,  occurs  to  us  whether  with  the  means  he  employs 
for  fixation  at  the  time  the  exacerbations  are  at  the  height 
would  not  accomplish  all  that  he  gains  by  the  additional 
drilling  ? 

I  can  see  how  an  early  drilling  with  the  limb  secured  in 
the  best  fixation  would  act  as  an  issue,  would  change  the 
character  of  the  inflammation,  and  would  thus  bring  about 
a  more  speedy  recovery.  One  reason  I  fancy  why  Mr. 
Macnamara  gets  stiff  joints  is  that  he  permits  too  much 
freedom  of  motion;  for  instance,  in  removing  the  splint  at 
night  and  substituting  therefor  the  weight  and  pulley. 
Then,  again,  I  think  his  drilling  would  serve  a  better  pur- 
pose in  the  early  stage  of  the  disease. 


390  DISEASES   OF  THE   HIP. 

It  will  be  seen  that  my  object  now  is  to  save  the  articular 
surfaces,  and  I  am  not  convinced  that  any  plan  of  treatment 
at  present  employed  will  accomplish  this  object  in  the 
majority  of  instances.  One  needs  to  know  this  fact  when- 
ever a  case  presents  in  its  incipiency.  An  anatomical 
diagnosis  is  essential  above  all  things.  Drilling  is  the 
only  operation,  except  an  early  excision.  Early  excisions 
will  never  be  popular,  for  the  reason  that  the  operation 
is  too  grave  in  appearance  for  so  apparently  simple  a  lesion. 
Free  incision  and  drainage  may  be  resorted  to,  but  even 
this  is  not  advised  unless  there  exist  epiphysial  necrosis. 

Operations  for  the  arrest  of  disease,  where  it  has  already 
advanced  to  the  destructive  stages,  consist  of  free  incision 
gouging,  and  excision.  The  latter  is  by  far  the  more 
common,  and  has  become  a  very  popular  operation  among 
general  surgeons.  The  orthopedist  who  relies  strictly  on 
mechanical  contrivances,  seldom  advises  such  extreme 
measures.  He  can  afford  to  await  the  slow  processes  of 
Nature  in  her  efforts  to  throw  off  the  effete  products.  He 
waits  occasionally  until  amyloid  degeneration,  or,  as  Mr. 
Barwell  prefers  to  call  it,  lardaceous  degeneration,  is  far 
advanced,  and  then  the  case  is  considered  hopeless. 

The  question  of  excision  no  longer  turns  on  the  mortality 
of  the  operation.  True,  the  danger  in  all  surgical  proce- 
dures is  to  be  considered,  yet  antiseptic  surgery  has  con- 
tributed largely  toward  removing  this  element.  When  I 
say  antiseptic  surgery  has  done  this,  I  mean  that  it  has 
done  so  directly  and  indirectly.  Those  surgeons  who  op- 
pose Listerism  have,  in  order  to  maintain  their  position, 
grown  more  cleanly  in  their  operations,  more  careful,  and 
more  discreet.  It  is  seldom  now  that  a  patient  dies  of 
shock  from  an  operation,  and  especially  from  an  excision. 
The  objections  that  the  extreme  conservatives  bring  up 
against  the  operation  are,  that  it  does  not  always  arrest 
the  disea.se,  and  that  it  does  not  leave  the  limb  so  use- 
ful as  when  a  cure  takes  place  in  the  natural  way.  These 
really  are  the  only  arguments  worth  considering,  and  the 
first  has  no  weight  as  an  argument.  When  one  decides 
that  there  is  no  hope  left  the  patient — that  he  must  surely 
die  by  exhaustion,  either  from  the  suppuration  or  the 
lardaceous  disease,  the  operation  of  excision  or  of  amputa- 
tion becomes  as  imperative  as  does  tracheotomy  when  a 
child  is  dying  from  laryngeal  stenosis.  No  man — even  its 
greatest  champion,  Dr.  Sayre — ever  claimed  that  excision 


TREATMENT  IN  CHRONIC  ARTICULAR  OSTITIS.    39! 

will  always  arrest  the  disease  and  save  life.  It  gives  the 
patient,  even  in  extremis,  the  last  hope,  and,  as  Dr.  Yale 
remarked  in  an  interesting  paper  before  the  Academy  of 
Medicine,  a  few  years  ago,  it  is  often  the  best  febrifuge  we 
can  command.  Indiscreet  enthusiasts  have  done  as  much 
as  the  extreme  conservatives  have  in  bringing  the  operation 
into  disrepute,  by  claiming  too  much.  When  one  looks 
over  statistical  tables,  and  sees  the  names  of  patients  re- 
ported as  cured,  patients  whom  he  knows  have  long  since 
succumbed  to  the  disease  for  which  the  operation  was  per- 
formed; when  he  sees  other  names,  with  the  result  given 
as  a  quarter  of  an  inch  shortening  and  a  very  useful  limb, 
patients  whom  he  knows  have  from  one  to  three  inches 
shortening,  and  who  use  a  cane  or  a  crutch;  when  he  sees 
names  of  patients  who  are  reported  as  free  from  disease, 
patients  whom  he  knows  to  be  suffering  from  draining 
sinuses  and  exacerbations  as  of  old — when  one,  I  say,  has 
an  experience  of  this  kind,  he  is  apt  to  condemn  the  opera- 
tion rather  than  the  statistician.  The  time  has  certainly 
come  when  excision  can  rest  on  its  merits.  Statistics  are 
to  it  as  a  fond  mother  is  to  her  favorite  child. 

Apart  from  the  unquestionable  relief  it  affords  to  suppu- 
rating joints,  it  has  been  conclusively  proven  during  the 
last  decade  that  lardaceous  degeneration  may  be  arrested  by 
this  means.  Cases  that  cannot  be  disputed  are  multiply- 
ing, and  before  long  the  evidence  will  be  overwhelming. 
Take  a  single  case,  one  among  several  that  have  corn- 
under  my  own  observation: 

In  1872  a  boy,  aged  eleven  years,  was  admitted  to  the 
hospital.  The  family  history  was  tuberculous.  The  his- 
tory states  that  when  he  was  two  years  of  age  he  was  lame 
in  the  right  hip  for  one  month,  but,  under  the  use  of  lini- 
ments, made  a  perfect  recovery,  and  was  active  and  free 
from  lameness  until  three  months  prior  to  admission  to 
hospital.  When  I  examined  him  I  found  as  he  stood  the 
right  limb  slightly  advanced,  and  the  foot  everted.  The 
weight  was  borne  chiefly  on  the  left  limb.  The  limp, 
while  characteristic,  was  very  slight.  There  were  the 
usual  changes  in  the  nates;  the  joint  and  trochanter 
were  tender;  the  joint  movements  were  limited  only  a 
very  little,  and  there  was  neither  shortening  nor  atrophy. 
In  other  words,  the  disease  was  in  the  first  stage  and  the 
prognosis  was  good,  i.e.,  from  the  views  I  then  held  con- 
cerning "  hip-disease." 


392  DISEASES   OF  THE   HIP. 

The  tenderness  subsided  within  a  month,  the  usual  hos- 
pital treatment  having  been  employed.  During  the  winter 
— three  or  four  months  after  admission — he  was  thin  and 
poorly  nourished,  but  the  hip  gave  no  annoyance  until  the 
following  summer,  when  after  an  exacerbation  the  second 
stage  was  fully  at  hand.  A  year  from  the  date  of  admission 
an  abscess  occupied  the  whole  of  the  gluteal  region,  and  a 
month  later  opened  spontaneously  over  the  coccyx.  The 
usual  hectic  followed,  but  it  was  not  severe,  and  he  had 
comparative  immunity  from  pain  until  the  approach  of 
another  exacerbation,  two  months  later,  more  acute  and 
more  distressing  than  any  h?  had  experienced.  At  this 
time  two  openings  existed,  and  through  one  a  spicula  of 
necrotic  bone  was  exfoliated. 

At  the  end  of  the  second  year  the  patient  was  feeble  in 
health,  the  limb  was  in  the  position  of  third  stage.  The 
soft  parts  were  dotted  with  ulcers  and  the  openings  of 
sinuses.  His  lungs  at  this  time  were  the  subject  of  much 
apprehension,  physical  signs  revealing  bronchial  changes, 
and  altogether  the  case  was  aught  but  hopeful.  During 
the  winter  no  marked  changes  occurred,  but  in  the  sum- 
mer— three  years  now  from  admission — the  urine  was  light 
in  color,  gave  on  standing  awhile  a  whitish  flocculent  de- 
posit, and,  on  the  addition  of  the  usual  test,  five  per  cent  of 
albumen.  In  the  field  of  the  microscope  it  furnished  an 
abundance  of  granular  and  hyaline  renal  tests.  This  par- 
ticular examination  was  made  July  9,  1875.  The  notes  for 
next  day  read:  "Little  or  no  oedema  present.  For  past 
week  has  complained  of  some  headache,  nausea,  and  con- 
stipation, the  significance  of  which  is  manifest  by  the 
urinary  examination." 

Another  examination  of  the  urine  was  made  a  fortnight 
later,  and  the  specific  gravity  was  1020,  while  the  specimen 
was  loaded  with  albumen.  I  found  also  on  examination 
hepatic  dulness  three  fingers'  breadth  below  the  free  border 
of  the  ribs.  A  month  afterward  he  was  discharged,  larda- 
ceous  degeneration  being  fully  established  and  the  suppura- 
tion being  unchecked.  The  prognosis,  as  recorded,  was, 
"death  from  amyloid  degeneration  within  three  years." 

The  boy  was  admitted  to  St.  Mary's  Hospital,  I  learned, 
shortly  afterward,  and  the  hip  was  there  excised  by  Dr. 
Poore,  who  has  already  placed  the  case  on  record. 

In  December,  1879, — four  years  after  the  operation — I  had 
an  opportunity  of  examining  the  boy,  and  I  found  his 


TREATMENT  IN  CHRONIC  ARTICULAR  OSTIT1S.    393 

general  appearance  excellent.  He  walked  without  any  sup- 
port save  a  high  shoe.  Without  this  he  used  a  crutch, 
although  he  could  bear  his  entire  weight  on  the  limb  with- 
out difficulty.  He  could  actively  flex  the  thigh  beyond  90° 
with  about  one  half  the  normal  force  ;  could  extend,  abduct, 
and  adduct  over  normal  arcs,  and  with  a  little  less  than  one 
half  the  normal  force.  The  cicatrices  all  seemed  old,  and 
there  were  no  open  sinuses  anywhere  to  be  seen.  The 
measurements,  as  I  found  them  at  that  time,  were  as  fol- 
lows: 

Right  side:  Thigh,  12^  in.;  knee,  n  in.;  calf,  10^  in.;  in- 
step, 8£  in. 

Left  side:  Thigh,  17  in.;  knee,  13  in.;  calf,  12^  in.;  instep, 
9^  in. 

The  right  limb  in  length  was  25^  in.,  the  left,  32$  in.;  the 
right  tibia,  12^  in.;  the  left,  14  in.;  the  right  foot,  8;  the 
left,  9.  He  had  no  cough  and  his  lungs  were  in  an  excellent 
condition.  Dr.  Ripley  examined  the  lungs  after  I  did  and 
fully  confirmed  the  result  I  had  obtained. 

The  condition,  as  described  by  Dr.  Poore  at  time  of 
operation,  was  as  follows: 

"At  the  time  of  his  admission  the  right  thigh  is  flexed, 
shortened,  and  inverted;  the  knee-joint  is  also  flexed  and 
stiff.  He-  suffers  much  pain,  so  that  he  is  confined  to 
the  bed  most  of  the  time;  he  lies  in  bed,  propped  up  with 
pillows;  he  has  not  been  able  to  lie  down  for  two  years.  [?] 
There  are  four  sinuses  about  the  joint,  through  most  of  which 
dead  bone  can  be  felt.  There  is  considerable  discharge. 
Patient  is  thin  and  pale;  appetite  poor;  liver  enlarged. 
There  is  some  albumen  in  his  urine,  but  no  casts  can  be 
found. 

"  On  May  2ist  the  joint  was  excised — present,  Drs.  Peters 
and  Watts.  The  head  of  the  bone  was  found  lying  in  the 
cavity  of  the  acetabulum  in  pieces;  the  neck  was  also  splin- 
tered; the  bone  was  divided  below  the  trochanter  minor; 
the  shaft  was  found  extensively  diseased;  the  bone  was 
soft,  thin,  dark-colored,  and  the  medullary  cavity  enlarged,  so 
as  to  easily  admit  the  finger  for  two  or  more  inches;  the  shaft 
was  divided  again  lower  down;  the  periosteum  was  loose; 
the  condition  of  the  bone  at  the  point  of  second  section 
showed  the  same  diseased  condition.  The  acetabulum  was 
not  perforated,  and  but  slightly  diseased. 

"Wound  brought  together  in  part,  and  patient  placed  in 
a  cuirass,  with  extension  so  as  to  bring  the  knee  down." 


394  DISEASES  OF  THE  HIP. 

The  important  point  about  my  examination  was,  that  I 
found  the  liver  dulness  normal — it  did  not  extend  below  the 
free  border  of  the  ribs.  I  had  him  pass  a  specimen  of 
urine,  and  I  found  it  of  a  specific  gravity  of  1012,  and  con- 
taining the  faintest  trace  of  albumen.  In  four  specimens 
examined  microscopically  I  could  not,  after  prolonged 
search,  find  any  casts  or  epithelium. 

I  have  since  seen  the  boy  about  the  streets,  and  he 
seemed  to  be  gaining  in  every  respect. 

There  are  many  cases  where  the  lardaceous  degeneration 
is  not  arrested  by  the  excision,  but  subsequent  amputation 
succeeds  in  arresting  this  process.  There  are  cases  wherein 
the  excision  has  failed  to  remove  all  the  disease  and  where 
the  suppuration  continues. 

Mr.  Barwell  reports  a  very  instructive  case  of  this  kind 
on  page  392  of  the  American  edition  of  his  work  on  "Dis- 
eases of  the  Joints."  The  patient  was  seven  years  of  age,  and 
Mr.  Hancock  had  performed  excision  twenty-two  months 
before.  When  amputation  was  performed,  "  the  liver  filled 
the  whole  right  side  of  the  abdomen,  its  lower  edge  being 
lost  within  the  crista  ilii;  it  extended  far  to  the  left  of 
the  middle  line;  the  spleen  was  large.  The  urine  was 
sufficient  in  quantity;  it  contained  albumen  and  some 
hyaline  casts,  none  of  which,  however,  were  of  the  smaller 
size,  and  were  mixed  with  endothelial  cells."  The  ampu- 
tation was  on  November  2d,  1872.  "She  made  a  rapid 
recovery;  the  wound  did  not  suppurate;  the  liver  and  spleen 
were  rapidly  diminished  in  size,  the  albuminuria  ceased, 
and  she  left  the  hospital  fat  and  strong,  on  February  i, 

1873-" 

In  September,  1880,  he  made  this  note:  "  I  have  seen  this 
girl  twice  since  the  amputation.  She  grew  very  rapidly, 
and  was  remarkably  strong  and  large.  During  the  month 
above  named  I  heard  of  her,  that  she  was  a  large,  strong, 
and  remarkably  healthy  woman." 

In  the  Medical  Times  and  Gazette  for  August  18,  1883, 
Mr.  R.  W.  Parker  details  a  case  that  is  full  of  interest  in  this 
connection.  The  child  was  two  and  a  half  years  of  age  in 
April,  1879,  when  admitted  to  the  East  London  Children's 
Hospital.  It  had  never  been  a  strong  child,  and  during  the 
few  months  preceding  admission  to  hospital  it  had  several 
"  small  abscesses"  in  different  parts  of  the  body,  for  instance, 
on  scalp,  back  axilla,  and  wrist.  Eleven  days  before  admis- 
sion the  right  buttock  was  similarly  affected,  and  when  Mr, 


TREATMENT  IN  CHRONIC  ARTICULAR  OSTITIS.    395 

Parker  saw  the  case  he  found  "a  large  fluctuating  swelling 
around  and  behind  the  trochanter,  the  skin  over  which  is 
normal."  The  thigh  was  held  in  slight  flexion  and  out- 
ward rotation,  but  there  was  "  no  pain  in,  or  fixation  of,  the 
hip-joint.'" 

The  abscess  was  very  promptly  opened  in  its  most  de- 
pendent part,  and  a  drainage  tube  inserted.  The  limbs 
were  fixed  in  the  extended  position  by  weight,  more  with  the 
idea  of  correcting  rachitic  curves  that  were  very  marked. 
A  month  later  pain  was  complained  of  about  the  hip,  and 
after  another  month  moving  of  the  limb  caused  considerable 
pain.  The  abscess  cavity  had  contracted,  and  a  probe  in- 
troduced did  not  come  in  contact  with  any  bare  bone. 
Disease  slowly  invaded  the  diaphysis  and  the  epiphysis, 
the  ordinary  signs  and  symptoms  accompanied,  and  two 
months  after  it  had  been  fully  recognized  excision  was  per- 
formed. The  head  of  the  bone  was  in  part  absorbed,  while 
the  remainder  was  necrotic.  "  The  neck  was  extensively 
carious,  soft,  and  fatty."  The  recovery  was  slow,  and  the 
child  was  sent  into  the  country  during  convalescence.  The 
sinuses  gradually  closed,  the  boy  grew  fat  and  looked  well. 
In  February,  1883 — fully  three  years  having  elapsed  since 
the  wounds  healed — he  came  under  observation  again  for 
"  dropsy."  The  wounds  were  still  healed,  but  the  cicatrices 
were  white  and  supple.  There  did  not  seem  to  be  any 
evidence  of  local  disease.  The  urine  was  loaded  with  albu- 
men, was  acid,  and  had  a  specific  gravity  of  1019.  Reme- 
dies were  administered  for  the  kidney  lesion — which,  by  the 
way,  was  supposed  to  be  scarlatinal  nephritis.  Two  weeks 
later  the  urine  was  more  copious  and  the  stools  were  watery. 
Vomiting  had  become  an  annoying  symptom.  Another 
week  elapsed  and  the  examination  of  the  urine  showed  it 
to  be  pale  straw-colored,  scanty,  and  almost  solid  on  boil- 
ing. No  casts  were  found,  and  no  blood-corpuscles.  The 
stools  became  more  frequent,  and  he  died  twenty-two  days 
after  coming  under  observation  for  his  "  dropsy." 

There  was  no  fluid  in  the  abdomen,  in  the  pleura,  or  in  the 
pericardium;  the  lungs  were  oedematous.  "  The  liver  was 
waxy,  and  weighed  twenty-seven  ounces  and  a  half;  the  kid- 
neys each  weighed  seven  ounces  and  a  half,  their  capsules 
readily  peeled  off;  the  cortical  substance  was  swollen  and 
the  whole  organ  pale.  The  joint  was  examined  carefully; 
it  was  at  first  hoped  that  a  specimen  of  repair  after  exci- 
sion would  have  been  found.  On  the  contrary,  a  process 


396  DISEASES  OF  THE  HIP. 

of  slow  caries  was  going  on  in  the  iliac  bone;  it  was  sur- 
rounded by  thick  inspissated  pus  which  had  raised  the 
periosteum  from  the  pelvic  surface  of  the  bone,  leaving  it 
finely  eroded.  The  upper  part  of  the  femur  was  connected 
to  the  remnants  of  the  old  capsular  ligament  by  firm,  un- 
yielding, gristly  connective  tissue." 

Mr.  Parker  very  properly  heads  his  report,  "  Peri-tro- 
chanteric  Abscess — Subsequent  Coxitis — Excision— Apparent  Re- 
covery— Lardaceous  Disease  three  years  later — Death — Autopsy." 

The  other  objection  to  the  operation,  viz.,  that  the  limb 
is  left  insufficiently  strong  as  a  support,  is  certainly  an  ob- 
jection worthy  of  consideration.  Still  this  is  of  insignifi- 
cant importance  when  compared  with  death  by  slow,  tor- 
turing suppuration. 

The  questions  then  are  reached: 

1.  Shall  we  ever  excise  ?    Yes. 

2.  In  what  cases  shall  we  excise  ? 

To  answer  this  question  let  me  cite  an  hypothetical  case 
or  two. 

Suppose  one  gets  a  case  in  the  early  stage,  and  learns  at 
that  time  or  subsequently  that  a  tuberculous  element  exists 
in  some  member  of  father's  or  mother's  family,  near  or 
remote.  Let  this  point  be  always  borne  in  mind  for  prog- 
nostic purposes.  Suppose,  furthermore,  that  the  treatment 
adopted  is  treatment  that  is  known  to  be  attended  usually 
with  a  fair  amount  of  success.  Suppose  resolution  does 
not  take  place,  but  that  the  disease  goes  into  the  second 
and  then  into  the  third  stages.  Suppose  the  suppurative 
process  is  unusually  severe  and  unusually  prolonged,  and 
that  the  patient  is  losing  ground  steadily  despite  treatment; 
suppose  that  the  urine  is  of  low  specific  gravity,  and  that 
this  low  specific  gravity  persists  until  the  child  begins  to 
complain  of  pain  in  the  hepatic  region.  Given  now  a  case 
like  the  above,  whether  the  evolution  have  been  slow  or 
rapid,  no  time  should  be  lost,  when  these  urinary  changes 
have  thus  advanced,  in  removing  every  particle  of  diseased 
bone.  If  excision  will  not  do  it,  resort  to  amputation.  Lard- 
aceous disease  is  impending,  and  life  is  at  stake. 

Suppose,  again,  in  this  same  patient  you  can  get  no  evi- 
dence at  any  time  of  a  tuberculous  element,  but  that  sup- 
puration has  existed  long  enough  to  induce  an  exceedingly 
low  vitality  and  is  accompanied  by  unexplained  attacks  of 
diarrhoea;  the  operation  should  then  be  done.  These  cases 
die  by  exhaustion,  and  these  little  disorders  of  the  intesti- 


TREATMENT  IN  CHRONIC  ARTICULAR  OSTITIS.    397 

nal  tract  are  but  the  precursors  of  a  general  dissolu- 
tion. 

Suppose,  still  again,  that  you  get  a  case  that  has  reached 
the  advanced  stages  without  treatment,  and  that  the  above 
conditions  exist;  it  is  useless  to  waste  time  with  any  forms 
of  mechanical  treatment. 

It  will  be  seen  that  I  have  placed  the  operation  on  the 
basis  of  a  necessity — a  last  resort.  If  time  be  an  important 
enough  element  in  the  case  it  may  be  performed  even  be- 
fore the  third  stage  is  reached.  I  do  not  know  but  that  the 
remarks  of  Mr.  Holmes  fairly  represent  my  own  views,  and 
I  take  pleasure  in  quoting  them,  as  does  Mr.  Macnamara: 

"  I  would  sum  up  what  I  have  to  say  about  excision  of 
the  hip  in  a  very  few  words,  by  the  simple  statement  that 
it  ought  to  be  very  rarely  indeed  required  if  the  disease 
were  treated  properly  at  its  commencement.  In  cases  seen 
at  an  advanced  stage  of  the  disease,  it  is  chiefly  when  se- 
questra exist  that  the  operation  is  necessary;  though  it  may 
be  advisable  as  a  means  of  shortening  the  treatment  in  other 
cases,  also,  when  the  patient  cannot  obtain  the  prolonged 
surgical  care  which  is  essential  to  natural  recovery." 

There  are  many  cases,  be  it  understood,  that  go  the  same 
way  after  excision,  and  if  lardaceous  disease  be  still  present 
amputation  should  be  performed.  After  all,  this  question 
must  be  left  to  the  good  sense  of  the  intelligent  practitioner, 
and  he  must  be  guided  in  addition  by  correct  surgical 
principles.  The  chances  of  life  and  death,  of  prolonged 
suffering  and  relief  from  suffering,  must  be  carefully 
weighed,  and  judgment  be  rendered  accordingly. 

Given  then  the  cases,  how  shall  the  operation  be  per- 
formed? There  are  several  incisions,  the  semilunar,  the 
vertical,  the  transverse,  and  the  T.  The  mode  of  operating, 
as  practised  by  Dr.  Sayre,  seems  to  be  the  most  generally 
accepted,  and,  with  antiseptic  precautions,  this  should  be 
done  as  follows: 

"  Select  a  strong  knife,  and  drive  it  home  to  the  bone  at  a 
point  midway  between  the  anterior-superior  spinous  pro- 
cess of  the  ilium  and  the  top  of  the  trochanter  ;  then,  draw- 
ing it  in  a  curved  line  over  the  ilium,  and  the  top  of  the 
great  trochanter,  extending  it,  not  directly  over  the  top  of 
the  trochanter,  but  midway  between  the  centre  and  its  pos- 
terior border,  and  complete  it  by  carrying  the  knife  forward 
and  inward,  making  the  whole  length  of  the  incision  from 
four  to  six  inches,  according  to  the  size  of  the  thigh.  In 


398  DISEASES   OF  THE   HIP. 

this  manner  a  curved  incision  is  made  through  all  the  soft 
parts  down  to  the  bone  and  through  the  periosteum.  If  you  do 
not  feel  certain  that  the  periosteum  has  been  divided  over  the 
femur  by  the  first  incision,  carry  the  point  of  the  knife 
along  the  same  line  a  second  and,  if  need  be,  a  third  time." 

Dr.  Wyeth  has,  by  anatomical  research,  demonstrated  that 
in  the  above  mode  of  making  the  incision  no  hemorrhage 
of  any  significance  is  encountered. 

The  parts  being  held  aside  by  retractors,  the  operator 
is  in  view  of  the  trochanter.  A  narrow  thick  knife  is  now 
used  for  a  "  second  incision  through  the  periosteum,  only  at 
right  angles  with  the  first,  at  a  point  an  inch  or  an  inch  and 
a  half  below  the  top  of  the  great  trochanter,  as  the  case  may 
be,  just  opposite  the  lesser  trochanter  or  a  little  above  it, 
and  extend  it  as  far  as  possible  around  the  bone."  The 
periosteum  is  detached  by  means  of  a  periosteal  elevator 
separating  the  attachments  up  to  the  digital  fossa.  The 
rotators  of  the  thigh  at  this  point  are  usually  divided  with 
the  knife.  Dr.  Sayre  lays  special  stress  on  the  smallness 
of  the  incision  in  this  locality,  and  upon  the  necessity  of 
elevating  enough  periosteum  in  order  that  the  muscular 
attachments  may  be  preserved. 

With  a  slight  adduction  movement  the  head  or  what  re- 
mains of  it  can  be  thrown  out  of  the  acetabulum,  the  sec- 
tion being  made  with  a  saw.  Some  prefer  the  chain,  some 
the  finger.  Bone  forceps  are  undesirable.  With  a  proper 
base  a  chisel  would  be  preferable,  as  no  sawdust  would  be 
left  as  an  irritating  substance. 

The  place  of  section  should  now  be  subjected  to  careful 
inspection  for  disease  of  the  shaft,  and  if  any  is  found  sec- 
tion must  be  made  at  a  lower  point.  It  will  naturally  sug- 
gest itself  to  the  operator  that  the  acetabulum  should  be 
carefully  explored  and  all  necrotic  bone,  so  far  as  practi- 
cable, removed.  Thorough  cleansing  antiseptically,  recti- 
fication of  deformity,  drainage  tubes,  and  appropriate  dress- 
ings comes  next  in  order. 

Dr.  Sayre  again  lays  stress  on  the  avoidance  of  cotton  or 
lint  as  plugs.  He  uses  oakum  soaked  in  balsam  Peru. 

As  a  splint  for  securing  immobility,  the  most  convenient 
is  the  modification  of  Bonnet's  grand  appareil  (figured 
as  No.  64).  This  is  well  padded,  and  the  patient  is  placed 
in  the  apparatus  the  sound  limb  being  strengthened  and 
secured  by  making  the  foot  fast  to  the  foot-piece,  which 
moves  by  an  adjustable  screw.  The  diseased  limb  is  se- 


TREATMENT  IN  CHRONIC  ARTICULAR  OSTITIS.    399 


cured  with  pads  about  salient  points  to  prevent  excoriation. 
This  can  be  worn  continuously  for  a  month  if  the  full 
Lister  dressing  be  employed;  otherwise  it  will  be  necessary 
to  change  the  dressing  in  from  twenty-four  to  forty-eight 
hours.  At  the  end  of  a  month  or  six  weeks  the  apparatus 
can  be  removed  and  other  splints  substituted. 

In  England  the  Bryant  splint  is  used,  with  modifications. 
Indeed  splints  which  preserve  the  parallelism  and  secure 
immobility  may  be  extemporized 
and  the  cuirass  can  be  dispensed 
with.  Works  on  surgery  give 
the  dressings  and  appliances  in 
detail;  but,  for  a  complete  de- 
scription, Dr.  Sayre's  work  on 
Orthopedic  Surgery  is  the  best 
for  reference.  This  operation 
is  successful  in  proportion  to 
the  care  in  execution  and  subse- 
quent nursing  given  the  patient. 

Some  surgeons  obtain  pei- 
mission  to  remove  the  limb, 
before  attempting  the  operation, 
in  case  the  disease  is  found  so 
extensive  as  to  make  the  re- 
moval of  all  portions  imprac- 
ticable. One  never  knows  just 
how  much  caries  he  will  meet. 
Sometimes,  as  in  one  or  two  of 
Dr.  Poore's  cases,  the  whole 
shaft  is  diseased. 

The  remaining  operations  are 
for  the  correction  of  deformity, 
and  to  Dr.  W.  T.  Bull  I  am  in- 
debted for  assistance  in  the  pre- 
paration of  the  remaining  por- 
tion of  this  chapter. 

The  operation  for  bony  ankylosis  consists  in  division  of 
the  neck  of  the  femur  with  a  saw  subcutaneously,  and  it 
has  been  done,  without  question,  with  good  results. 

It  has  also  been  done  with  a  chisel  by  Volkmann,  Maun- 
der and  Macevven.  It  makes  very  little  difference  whether 
the  bone  is  divided  with  a  saw  or  chisel.  Of  late  years 
most  surgeons  prefer  the  chisel  to  the  saw.  In  either  case 
the  operation  is  practically  the  same:  sink  the  knife  right 


FIG.  64. 


4OO  DISEASES   OF  THE  HIP. 

down  to  the  bone  above  the  upper  border  of  the  great  tro- 
chanter,  and  then  either  pass  a  saw  or  a  chisel  through  this 
opening  and  divide  the  bone. 

Theoretically,  the  saw  is  open  to  the  objection  of  leaving 
sawdust  behind,  but  both  means  give  uniformly  good  re- 
sults. The  wound  generally  heals  perfectly,  or  with  very 
moderate  suppuration.  Some  wounds,  when  the  bone  is 
divided  with  the  saw,  heal  subcutaneously.  It  is  desirable 
to  do  such  operations  antiseptically  as  far  as  possible. 

Adams's  operation  is  only  practicable  in  cases  of  bony 
ankylosis  where  the  head  of  the  bone  is  in  its  place,  and 
these  are  cases  of  ankylosis  from  rheumatism  or  rheumatic 
arthritis,  ankylosis  from  long-continued  rest,  and  Adams 
includes  pysemic  inflammation  of  the  hip-joint — in  fact  any 
inflammation  where  the  head  of  the  bone  remains  in  place; 
as  long  as  the  head  is  there,  the  operation  is  feasible. 

But  cases  of  hip-joint  disease  where  the  head  of  the 
bone  has  been  absorbed,  where  there  is  a  high  position 
of  the  trochanter  above  Nelaton's  line  are  not  amenable 
to  Adams's  operation. 

Such  cases  require  an  operation  first  performed  by  Barton, 
but  which  should  be  done  nowadays  after  the  manner 
made  more  precise  by  Volkmann. 

Barton's  operation  consisted  in  cutting  through  the 
femur  below  the  trochanter  minor.  An  incision  was  made 
sufficiently  large  to  separate  the  periosteum  from  the  bone, 
and  then  a  chain-saw  was  passed  around  the  bone,  thus 
dividing  it.  Several  American  surgeons  repeated  this 
operation.  Sayre  modified  it  by  making  one  end  of  the 
bone  convex  and  the  other  concave,  and  claimed  to  obtain 
motion  by  this  artificial  joint,  which  persisted  for  two 
years  (reported  on  page  420  of  his  work).  There  is  an 
objection  to  this  operation  proposed  by  Barton,  from  the 
fact  that  the  bone  is  cut  completely  across,  and  when  the 
effort  is  made  to  straighten  the  limb,  it  is  likely  to  throw 
upward  or  forward  the  upper  end  of  the  lower  fragment. 
One  case  occurred  in  the  practice  of  a  surgeon  in  this  city, 
in  which  the  femoral  artery  was  pressed  upon  and  gan- 
grene took  place. 

The  Volkmann  operation  is  the  one  Dr.  Bull  performs. 
In  this  the  bone  is  not  sawn  or  chiselled  entirely  through, 
but  a  wedge-shaped  piece  is  removed  from  the  outer  sur- 
face of  the  bone,  the  apex  of  which  extends  nearly  to  the 
compact  tissue  on  the  inner  surface  of  the  bone.  This 


TREATMENT  IN  CHRONIC  ARTICULAR  OSTITIS.    401 

leaves  a  thin  layer  of  compact  tissue  on  the  inner  surface  to 
be  fractured  through  in  the  effort  to  straighten  the  limb, 
and  serves  to  hold  the  lower  fragment  in  place. 

In  addition  to  removing  the  wedge-shaped  piece  of  bone, 
it  is  generally  necessary  to  divide  the  sartorius,  tensor 
vaginae  femoris,  and  sometimes  the  rectus  where  the 
thigh  is  strongly  flexed;  and  in  addition  to  these  muscles 
the  adductors  also  should  be  divided  when  the  limb  is 
adducted  as  well  as  flexed. 

The  operation  to  which  Volkmann  gave  the  name  "Sub- 
trochanteric  Osteotomy,"  is  performed  as  follows:  An  in- 
cision is  made  directly  over  the  long  axis  of  the  femur  on 
its  outer  side,  about  one  and  a  half  inches  in  length,  di- 
rectly down  to  the  bone.  The  middle  point  of  this  incision 
should  be  from  one  to  one  and  a  half  inches  below  the  top 
of  the  great  trochanter.  The  periosteum  is  separated  from 
the  bone  over  the  outer  and  posterior  surface,  and  with  the 
chisel  a  wedge-shaped  piece  is  removed  embracing  the 
whole  thickness  of  the  bone,  with  the  exception  of  the  inner 
layer  of  compact  tissue.  The  width  of  the  base  of  the 
wedge  should  be  greater  or  less  according  to  the  amount 
of  flexion,  and  the  base  of  the  wedge  must  be  sufficiently 
large  to  permit  the  cut  surfaces  of  the  bone  to  come  in 
contact  when  the  limb  is  straightened.  This  varies  from 
one  half  to  one  inch. 

After  removing  the  wedge  of  bone,  the  pelvis  should  be 
steadied  by  an  assistant,  and  the  limb  brought  down  to  a 
straight  position  by  fracturing  the  layer  of  bone  which  has 
not  been  cut  through,  and  before  the  limb  can  be  perfectly 
straightened  it  may  be  found  that  division  of  the  adduc- 
tors sartorius  and,  sometimes,  the  tensor  vaginae  femoris 
is  required.  This  may  be  done  by  subcutaneous  incision 
or  by  an  open  wound;  probably  the  former  method  will 
suffice  in  the  majority  of  cases,  and  is  to  be  preferred  on 
account  of  the  smaller  or  insignificant  character  of  the 
wound.  If,  however,  extensive  division  of  these  muscles 
should  be  found  necessary,  some  surgeons  prefer  to  accom- 
plish this  by  the  open  method. 

The  subcutaneous  tenotomy  (myotomy  ?)  is  easily  per- 
formed, by  putting  the  muscles  on  the  stretch  by  straight- 
ening the  limb,  entering  the  skin  close  to  their  origin 
with  a  sharp-pointed  tenotome,  then  passing  a  blunt- 
pointed  tenotome  underneath  the  muscle,  taking  care  to 
keep  close  to  the  point  of  insertion  in  the  bone  and  cut- 
F  l-K 

L 


4O2  DISEASES  OF  THE  HIP. 

ting  toward  the  skin  while  the  fibres  are  kept  upon  the 
stretch. 

The  wounds  should  be  kept  open  and  covered  merely 
with  a  Lister  dressing,  which  should  reach  from  the 
lower  third  of  the  thigh  to  the  crest  of  the  ilium.  Over 
this  a  plaster-of- Paris  bandage  should  be  applied  from 
above  the  knee,  embracing  the  pelvis,  and  a  weight-and- 
pulley  extension  applied  to  the  limb,  a  weight  of  five  or  ten 
pounds  being  sufficient.  In  place  of  the  extension  and 
plaster-of-Paris,  a  long  external  splint,  reaching  from  the 
axilla  to  below  the  sole,  should  be  used  in  young  children. 

This  operation  has  yielded  perfectly  satisfactory  results 
only  where  antiseptic  details  have  been  strictly  carried  out; 
and  while  it  is  no  longer  considered  necessary  to  use  the 
spray  upon  a  wound  during  operations,  it  is  certainly  de- 
sirable that  the  parts  to  be  operated  on,  the  instruments, 
and  hands  of  the  operator  and  his  assistants,  should  be 
carefully  disinfected,  and  a  typical  Lister  dressing  should 
be  used.  In  view,  however,  of  carbolic-acid  poisoning  in 
children,  especially  those  of  a  strumous  diathesis,  it  seems 
to  Dr.  Bull  at  least  preferable  to  substitute  for  carbolic  acid 
in  the  wound  a  solution  of  bichlorde  of  mercury,  of  the 
strength  of  one  part  to  one  thousand. 

The  dressing  need  not  be  removed  unless  a  discharge 
appear  at  its  edge,  or  there  be  some  constitutional  distur- 
bance. 

At  the  end  of  six  weeks  union  will  have  occurred  at  the 
point  of  section  of  the  bone,  and  a  week  or  two  later  the 
patient  may  be  allowed  to  go  around  on  crutches.  In 
many  cases  the  wound  in  the  soft  parts  will  be  reduced  to 
a  mere  granulating  surface,  or  entirely  cicatrized  at  the 
end  of  three  weeks,  and  a  more  simple  dressing  may  be 
substituted  for  the  Lister  gauze. 


. 


INDEX. 


Abductors  of  hip,  35 

Abscesses,    are    they   desirable    in 

chronic  articular  ostitis,  325 
Abscess  above  Poupart's  ligament, 

46 

—  in  articular  ostitis  and  lumbar, 
Pott's,  312 

—  extracapsular,  94 

—  disappearance  of,  258 

—  ischio  rectal,  significance  of,  45 

—  premonitions  of,  241 

—  perineal,  significance  of,  46 

—  rectal,  significance  of,  46 

—  residual,  how  managed,  325 
Acetabulum,  points  of  perforation 

of,  45 

Acquired  struma.  212 

Adams,  Mr.  Wm.,  operation  for 
ankylosis,  400 

Adductors  of  hip,  34 

Age  as  a  predisposing  cause  in  ar- 
ticular ostitis,  207 

Allis,  Dr.  Oscar,  on  nature's  cure, 
322 

American  method  of  treating  joint- 
diseases,  358 

Amputation  at  hip-joint  for  larda- 
ceous  degeneration,  394 

Amyloid  disease  (see  Lardaceous 
disease) 

Amyloid  degeneration  after  suppu- 
ration, 222 

,  relieved  by  dislocation,  265 

Anatomy  of  hip,  30 

Andrews,  Dr.,  the  ischiatic  crutch, 
358 

Angle  of  deformity,  mode  of  meas- 
urement of,  27 

Annandale,  Prof. ,  on  osteo-myebitis, 

197 
Articulation,  the,  44 


Arthritis,  acute,  of  infants,  22 

—  rheumatic.  80 

—  chronic  rheumatic  in  the  adult, 
86 

Articular  ostitis  of  the  hip,  chronic, 
pathology  of,  170 

,  chronic,  diagnosis  of,  268 

,  treatment  by  drilling  tro- 

chanter,  388 

,  incompleteness  of  cure  of,  268 

Baker,  Mr.  W.  Morrant,  on  Epi- 
physal  Necrosis,  23 

Banks,  Mr.  Mitchell,  on  operative 
procedures  in  Bursitis,  117 

Barton,  Dr.  J.  M.,  case  of  trau- 
matic diastasis,  151 

Barton's  operation  for  deformity, 
400 

Harwell,  Mr  ,  case  of  lardaceous 
degeneration  arrested  by  ampu- 
tation. 394 

—  hip-splint,  369 

Bauer,  Dr.,  on  the  diagnosis  of 
diastasis,  147 

—  hip  splint,  359 
Belladonna  in  periostitis,  160 
Berry,  Dr.  John  James,  on  the  fara- 

dic  current  in  ostitis,  232 
— ,  on  juxtaepiphysial  congestion, 

174 

Billroth,    Prof.,    on    residual    ab- 
scesses, 325 
— ,  on  the  various  forms  of  ostitis, 

187 

Blisters  followed  by  poultices,  132 
Blood  supply  to  muscles  of  hip,  36 
Bradford.  Dr.,  on  the  physiological 

method.  343 

— ,  on  the  Thomas  method,  356 
Brisement  force  in  chronic  ostitis 
dangerous,  58 


404 


INDEX. 


Brisement  ford  in  rheumatic  peri- 
arthritis,  85 

Brodhurst,  Mr.,  mode  of  treating 
ankylosis,  86 

Brodie,  Sir  Benj.,  on  hysterical 
joints,  59 

Bryant,  Mr.  Thomas,  splint  for 
maintaining  parallelism,  370 

Bull,  Dr.  Wm.  T.,  case  of  necrosis 
of  Ilium,  operation,  105 

—  case  of  acute  synovitis,  125 
Bursae  about  the  hip,  36 
Bursitis  of  the  hip,  no 

— ,  etiology  of,  no 

—  producing  articular  ostitis,  117 
— ,  treatment  of,  114 

— ,  prognosis  of,  117 

Cases  (see  Supplementary  Case  In- 
dex) 

Cautery,  the  actual,  in  neuroses, 
72 

Centres  of  ossification  of  femur,  47 

of  pelvis,  46 

Chance,  Mr.  E.  J.,  apparatus  for 
the  hip,  372 

Cheever,  Dr.,  on  inflammation  of 
deep  fascia  of  thigh,  104 

Chronic  articular  ostitis,  clinical 
history,  226 

,  etiology  of,  203 

,  methods  of  treatment,  320 

of  the  hip,  pathology  of,  170 

,  the  physiological  treatment 

of,  338 

Chronic  rheumatic  arthritis,  diag- 
nosis of,  91 

,  treatment  of,  92 

"  Click,"  a  peculiar  in  Bursitis,  113 

— ,  a  peculiar  in  neuromimesis,  113 

Clinical  history  of  chronic  articular 
ostitis,  226 

Clinical  picture  of  the  third  stage, 

259 

Clippingdale,  Dr.,  "On  Hip  Dis- 
ease," 45 

Complications  of  articular  ostitis, 
260 

Contusions,  50 

Crease,  Ilio-femoral,  31 

Cry,  ostitic,  238 

Cure,  difficulty  of  establishing, 
260 

— ,  the  incompleteness  of,  in  ar- 
ticular ostitis,  268 


Danger  of  passive  motion  in  adhe- 
sions from  chronic  ostitis,  58 
Definition  of  hip,  30 

—  of  first  stage  of  articular  ostitis, 
226 

—  of  a  neurosis,  59 
Deformity,    correction   of    by   the 

Thomas  splint,  354 
— ,  mode  of  reducing  by  the  long 

splint    plus    weight   and   pulley, 

361 

— ,  measurement  of  angle  of,  27 
Diagnosis,    the  importance  of,    in 

orthopedic  surgery,  269 

—  of  articular  ostitis,  268 

—  of  articular  ostitis,  cases  illustra- 
tive of,  277 

—  of  articular   ostitis    first    stage 
functions  of  the  joint,  272 

—  of  articular  ostitis,  table  of  dis- 
eases from  which  differentiated, 
278 

—  of  articular  ostitis   first   stage, 
signs  on  inspection,  271 

—  of   articular  ostitis    first   stage, 
signs  on  palpation,  272 

—  between    articular    ostitis    and 
bursitis,  291 

—  between    articular    ostitis    and 
exostosis,  305 

—  between  articular  ostitis  and  in- 
fantile spinal  paralysis,  285 

—  of  articular  ostitis — points  be- 
tween this  and  neuroses,  285 

—  between    articular    ostitis    and 
ostitis  of  Ilium,  297 

—  between    articular    ostitis    and 
periarthritis,  289 

—  between    articular    ostitis    and 
periostitis,  295,  296 

—  of  articular  ostitis,  cases  of  peri- 
ostitis, 295 

—  of  articular   ostitis — points  be- 
tween this  and  rheumatism,  283 

—  between    articular    ostitis    and 
sacro-iliac  disease,  298-300 

—  of  articular  ostitis,  tabular  state- 
ment regarding  sprains,  280 

—  of  articular   ostitis,  from  acute 
synovitis,  292,  294 

—  of  articular  ostitis,  case  of  recur- 
ring synovitis,  293 

—  between    articular    ostitis    and 
vertebral  ostitis,  301,  305 


INDEX. 


405 


Diagnosis  of  articular  ostitis,  cases 
of  Pott's  disease,  301 

—  between    articular    ostitis    and 
lumbar  Pott's  disease,  312 

—  of  the  second  stage  of  articular 
ostitis,  306 

—  between  second  stage  of  articu- 
lar ostitis  and  acute  epiphysitis, 
315 

—  of  articular  ostitis,  from  the  fe- 
moral abscess  of  Pott's  disease, 
313 

—  between    articular    ostitis    and 
Iliac  abscess,  309 

—  of  articular  ostitis,  cases  of  per- 
inephritis,  306,  308 

—  between  second  stage  of  articu- 
lar ostitis  and  perityphlitis,  309 

—  of  articular  ostitis,  cases  of  peri- 
typhlitis,  309 

—  between  second  stage  of  articu- 
lar ostitis   and    Pott's    disease  ; 
tabular  statement,  314 

—  of  articular  ostitis,  third  stage, 
316 

—  of  articular  ostitis  third  stage, 
case   of   rheumatic  periarthritis, 
3i8 

—  of  articular  ostitis,  third  stage, 
case    of     traumatic    dislocation, 

317 

—  of  epiphysitis,  142 

—  of  muscular  rheumatism,  79 

—  of  neuroses,  68 

—  of  periarthritis,  99,  103 

—  of  rheumatic  arthritis,  84 

—  of  chronic  rheumatic  arthritis,  91 

—  of  periostitis,  156 

—  of  periost-eal  sarcoma,  167 

—  of  sprains,  54 

—  of  synovitis,  128 

Diastasis  of  the  head  of  the  femur, 
146 

—  versus  Epiphysitis,  140 

— ,  traumatic,  lesions  from  which 
differentiated,  151 

— ,  traumatic,  extreme  infrequency 
of,  140 

— ,  treatment  of,  151 

Dislocation,  spontaneous,  Mr.  Hil- 
ton on,  263 

— ,  pathological,  262 

Double  articular  ostitis,  frequency 
of,  24 


Duplay,    M.,    on    scapulo-humeral 

periarthritis,  94 
Duration  of  second  stage,  247 

—  of  third  stage,  259 

—  of  synovitis,  133 
Epiphysial  necrosis,  23 
Epiphysitis  of  the  hip,  acute,  135 
— ,  diagnosis  of,  142 

—  versus  Diastasis,  140 

— ,  lesions  from  which  differen- 
tiated, 145 

— ,  pathology  of,  135 

— ,  prognosis  of,  145 

— ,  strumous  versus  syphilitic,  142 

— ,  treatment  of,  146 

Esmarch  on  neuroses,  60 

Etiology  of  chronic  articular  ostitis, 
203 

—  of  articular  ostitis,  conclusions, 
225 

—  of  bursitis,  no 

—  of  joint-disease,  statistics,  212 
Eve,   Mr.,  on  epiphysial  necrosis, 

23 

Exacerbations  induced  by  trauma- 
tism,  244 

—  in  neuroses,  283 

— ,  signs  indicating  approach  of,  271 
— ,  significance  of,  241 
Examination,  danger  in  rough,  273 
Exanthemata  developing    struma, 
212 

Excision,  390 

— ,  lardaceous  disease  three  years 
later,  394 

— ,  when  shall  the  operation  be  per- 
formed, 396 

— ,  the  wire  cuirass  after,  396 

Expectant  treatment  in  chronic  ar- 
ticular, 324 

,  definition  of,  321 

,  claims  of,  333 

,  conclusions,  333 

Extensors  of  hip,  34 

Faradic  current  in  diagnosis  of  os- 
titis, 232 

Fasciae  of  hip,  36 

Family  history  in  neuroses,  value 
of,  66 

Flexion,  resistance  to,  as  diagnos- 
tic, 237 

Flexors  of  hip,  33 

Fricke's  case  of  ostitis  of  the  hip, 
185 


406 


INDEX. 


Garrod,  Dr.,  on  definition  of  rheu- 
matism, 75 

Geib,  Dr.  H.  P.,  case  of  chronic 
rheumatic  arthritis,  93 

Goniometer,  Dr.  Knight's,  274 

Gosselin,  M.,  on  Tibio^femoral  pe- 
riarthritis,  94 

Gross,  Dr.  S.  W.,  on  sarcoma  of 
the  long  bones,  162 

Gross,  Dr.  S.  D.,  syphilis  as  a  pre- 
disposing cause  of  bone-disease, 
208 

Hugman,  Mr.,  the  inclined  plane 
for  "hip-disease,"  370 

Hamilton,  Dr.  Frank,  on  diastasis, 

147 

— ,  wire-gauze  splint,  344 

Hemingway,  Dr.  S.,  case  of  epi- 
physitis,  143 

Heredity,  phases  of,  209 

Hilton  on  spontaneous  dislocation, 
263 

Hip,  definition  of,  30 

"  Hip-limp,"  233 

"  Hip  disease,"  double,  24 

Hip-splints,  the  abuse  of,  372 

Hip-splint,  Dr.  Roberts',  376 

History  of  cases,  mode  of  obtain- 
ing, 214 

History  and  record  of  case,  sched- 
ule for,  28 

Histories,  worthlessness  of  many, 

234 

Holmes,  Mr.  T.,  on  excision,  397 
— r  on  chronic    joint   disease   de- 
veloping struma,  221 
Holt,  Dr.  L.  E.,  case  of  sarcoma  of 

the  hip,  165 
Hot  fomentations  in  periarthritis, 

107 

Hot-water  douche  in  neuroses,  66 
Hutchison,  Dr.  Jos.,  hip-splint,  360 
— ,  on  the  physiological  treatment 

of  articular  ostitis,  338 
Hysterical  element  in  neuroses,  69 
Immobilization  in  articular  ostitis, 

357 

Infantile  spinal  paralysis,  diagnos- 
ticated from  articular  ostitis  first 
stage,  285 

Inspection  in  diagnosis,  271 

Inward  rotators  of  hip,  35 

Iliac  abscess,  differentiated  from 
articular  ostitis,  309 


Ilio-femoral  crease,  31 

Irregular  type  of  ostitis,  129 

Ischio-rectal  abscess,  significance 
of,  45 

Jacobi,  Dr.  A.,  on  the  development 
of  bone,  209 

Jane  way,  Dr.  E.  G.,  report  on  cases 
of  ostitis,  183,  193 

Joint  functions  in  diagnosis,  272 

—  lesions,  multiple,  25 

— ,  sensitiveness  of,  in  diagnosis, 
276 

Judson,  Dr.  A.  B.,  case  and  speci- 
men of  epiphysitis,  136 

— ,  on  pathology  of  "  hip-disease," 
171 

— ,  the  U-shaped  attachment  for 
better  fixation,  365 

Knee-pain,  not  confined  to  first 
stage,  254 

Knight,  Dr.  James,  a  goniometer, 
274 

— ,  on  the  mode  of  employing 
blisters,  132 

Lardaceous  degeneration  after  sup- 
puration, statistics  of,  224 

dependent  on  tubercular  dia- 
thesis, 267 

duration  of,  267 

developing  three  years  after 

excision,  394 

Leather  splint,  Dr.  Vance's,  345 

Ligaments  of  hip, 
capsular,  38 
cotyloid,  38 
teres,  or,  round,  38 
transverse,  38 
Ilio-femoral,  40 
Ischio-femoral,  40 

Ligamentum  teres,  as  primarily  af- 
fected, 172 

Liver,  the  border  of,  in  lardaceous 
changes,  194 

Long  splint  used  by  Dr.  Sayre,  363 

Long  splint,  mode  of  applying,  365 

Lordosis  complicating  articular  os- 
titis, 267 

Macnamara,  Mr.  C.,  results  of 
drilling  trochanter  for  articular 
ostitis,  388 

— ,  on  epiphysitis,  136 

Malaria  as  a  cause  of  neuroses,  71 

Malignant  disease  of  the  hip,  161 

Malum  coxx  senile,  86 


INDEX. 


407 


Malum  coxae  senile,  rarely  com- 
plete ankylosis  in,  87 

March,  Dr.  Alden,  on  pathological 
dislocation,  264 

Martin,  Dr.,  case  of  bursitis,  113 

Mayer,  Dr.  E. ,  case  of  osteo-peri- 
ostitis,  104 

Measurement  for  length  of  limb,  28 

Meningeal  hyperaemia,  a  cause  of 
neuroses,  63 

Meningitis,  tubercular,  complicat- 
ing articular  ostitis,  264 

Mitchell,  S.  Weir,  on  spinal  arthro- 
pathies,  60 

Morris,  Mr.  Henry,  on  anatomy  of 
the  joint,  37 

,  on  function  of  round  liga- 
ment, 42 

Movements  of  hip,  normal,  46 

Multiple  joint  lesions,  25 

Muscles  of  hip,  classification,  32 

Muscular  rheumatism  of  the  hip, 

74 

Myalgia,  of  rheumatic  nature,  75 
Nates,  changes  in,  value  of,  237 
Nerve  supply  to  abductors,  35 

to  adductors,  34 

to  extensors,  34 

to  flexors,  33 

to  inward  rotators,  36 

to  outward  rotators,  35 

Neuroses,  59 

— ,  the  actual  cautery  in,  72 

— ,  complicating  chronic   articular 

ostitis,  65 

— ,  diagnosis  of,  68 
— ,  malaria  as  a  cause  of,  71 
— ,  meningeal  hyperaemia,  the  pa- 
thology of,  63 
— ,  prognosis  in,  73 
— ,  relapses  in,  62,  69 
— ,  treatment  of,  69 
Neuromimesis,  a  case  of  Dr.  Shaf- 
fer's, 63    . 

Normal  movements  of  hip,  46 
Obturator  internus,  its  relation  to 

pus-tracts,  45 

Oilier,    M.,    on   epiphysial   hyper- 
aemia from  traumatism,  174 
Operations  for  the  arrest  of  articu- 
lar ostitis,  390 
Operation  for  deformity,  Barton's, 

400 
,  Volkman's,  400 


Ossification,  centres  of,  46 

—  of  femur,  47 

—  of  pelvis,  46 
Ostitic  cry,  238 

Ostitis,  articular,  depending  on  a 
bursitis,  117 

— ,  chronic,  articular  double,  fre- 
quency of,  24 

—  of  hip  with  neurotic  symptoms, 
65 

—  of   Ilium,    diagnosticated   from 
articular  ostitis,  297 

— ,  peripheral,  24 

Osteotomy,  subtrochanteric,  400 

Osteo-myelitis,  its  relationship  with 

articular  ostitis,  196 
Outward  rotators  of  hip,  35 
Paget,  Sir  James,  on  the  cause  of 
atrophy,  232 

,  on  neuromimesis,  59 

Pain  in   knee,  not  limited   to  first 

stage,  254 
Pain  in  ostitis,  234 
Palpation  in  diagnosis,  272 
Parker,  Mr.  R.  W.,  case  of  articu- 
lar ostitis;    excised — subsequent 
development  of  lardaceous   dis- 
ease; death:  autopsy,  394 
Parker,  Dr.  Willard,  case  of  Dias- 

tasis,  148 

Passive  motion  under  ether  in  ad- 
hesions following  sprains  and 
contusions,  57 

Pathology  of  chronic  articular  os- 
titis, summary,  201 

—  of  chronic  articular  ostitis  of  the 
hip,  170 

—  of  epiphysitis,  135 

Pattern  for  Dr.  Vance's  splint,  346 
Perforation  of  acetabulum,  points 

of,  45 
Periarthritis,  coxo-femoral,  94 

—  diagnosis  of,  99 

—  fibrinous,  94 

—  points  in  differential  diagnosis 
of.  103 

—  rheumatic,  80-82 

—  prognosis  of,  103 

—  statistics  of,  95 

—  treatment  of,  107 

—  pathology  of,  94 

—  phlegmonous,  94 
Periosteal  Sarcoma,  diagnosis  of, 

167 


408 


INDEX. 


Periosteal  Sarcoma, statistics  of,  167 

Periostitis  of  the  hip,  153 

— ,  acute  diffuse,  161 

— ,  diagnosis  of,  156 

— ,  period  of  life  when  most  fre- 
quent, 153 

— ,  causes  of,  153 

— ,  prognosis  of,  161 

— ,  treatment  of,  160 

Perinephritis,  differentiated  from 
second  stage  of  articular  ostitis, 
306 

Physiological  treatment  of  chronic 
articular  ostitis,  338 

Poore,  Dr.  C.  T.,  on  osteo-myelitis, 
196 

,  cases  of  sacro-iliac  disease, 

299 

Post,  Dr.  Alfred  C.,  case  of  dias- 
tasis,  148 

Position  of  limb,  best,  for  locomo- 
tion when  ankylosed,  322 

Pott's  disease  differentiated  from 
articular  ostitis,  301 

Poultices,  following  blisters,  132 

Practical  shortening,  28 

Probe,  the  value  of,  105 

Prognosis  of  bursitis,  117 

—  of  epiphysitis,  145 

—  in  neuroses,  73 

—  of  periarthritis,  103 

—  of  periostitis,  161 

—  of  synovitis,  128 
Real  shortening,  28 

Record  of  case,  schedule  for,  28 
Reflex  spasm  in  ostitis,  235 
Relapses  in  neuroses,  62,  69 
Rest  in  the  treatment  of  contusions, 

57 

Result,  best  attainable,  in  chronic 

articular  ostitis,  322 
Results  of  treatment  by  the  long 

splint,  380 
Results  of  treatment  by  the  Thomas 

method,  356 

Rheumatism  of  the  hip,  74 
— ,  muscular,  diagnosis  of,  79 
— ,  treatment  of,  85 
— ,  scientific  dread  of  term,  74 

—  following  traumatic  cellulitis,  78 
Rheumatic  arthritis,  diagnosis  of, 84 

,  chronic,  symptoms  of,  91 

Rheumatic  periarthritis,  brisement 

force  in,  85 


Ripley,  Dr.  J.  H.,  case  of  rheuma- 
tic arthritis  treated  by  free  pas- 
sive motion,  86 

Roberts,  Dr.  M.  Josiah,  hip  splint, 
376 

Rotators  of  hip  inward,  35 

outward,  35 

Round  ligament,  function  of,  42 

Round-celled  periosteal  sarcoma, 
162 

Sacro-iliac  disease  diagnosticated 
from  articular  ostitis,  298 

,  cases  of,  299 

Savory,  Mr.  Scovell,  on  analogy 
between  pulmonary  and  epiphy- 
sial  tissue,  176 

Say  re,  Dr.  Lewis  A.,  cases  of 
diastasis,  138 

— ,  operation  for  excision,  397 

— ,  short  splint,  371 

Sciatica,  a  point  in  differentiating 
from  joint  disease,  91 

Schoeneman,  Dr.,  case  of  perios- 
titis, 159 

Schedule  for  history  and  record  of 
case,  28 

Scott,  Dr.  M.  T.,  case  of  articular 
rheumatism,  79 

Sector  splint,  373 

Sensitiveness  of  bone  and  joint  in 
diagnosis,  276 

Shaffer,  Dr.  Newton  M.,  on  a  case 
of  neuromimesis,  63 

— ,  on  traumatism,  217 

— ,  on  the  faradic  current  in  diag- 
nosis, 232 

Shortening,  real  and  practical,  28 

Short  splint  of  Dr.  Sayre,  371 

Smith,  Mr.  Noble,  on  hip-splints, 
372 

Smith,  Dr.,  Henry  H.,  on  the  me- 
dulla of  bones,  188 

Smith,  Mr.  Thomas,  on  the  diag- 
nosis of  acute  epiphysitis,  315 

Spaulding,  Dr.  G.  A.,  on  the  sequel 
of  a  case  of  neuromimesis,  64 

Spinal  deformities  complicating 
articular  ostitis,  267 

Sprains,  diagnosis  of,  54 

— ,  treatment  of,  56 

— ,  50 

Sprain,  symptoms  of,  52 
Stage,  first,  of  articular  ostitis  de- 
fined, 226 


INDEX. 


409 


Stage,  first,  symptoms  of,  239 
Stages,  the  insidious  passage  from 
first  to  second,  246 

—  of   treatment   by   the    Thomas 
method,  355 

,  of  articular  ostitis,  diagnosis 

of,  306 
Stage,  second,  deformity  of,  249 

,  definition  of,  240,  247 

,  symptoms  of,  248 

,  duration  of,  247 

— .  third,  definition  and  symptoms 

of,  250 

,  clinical  picture  of,  259 

,  duration,  259 

Statistics  of  periarthritis,  95 

—  in  joint  disease,  as  to  etiology, 
212 

— ,  Dr.  C.  F.  Taylor's,  382 
Struma  as  related  to  tubercle,  204 

—  as  developed   by    suppuration, 
221 

—  developed  by  the  exanthemata, 
212 

Strumous  element  in  etiology,  206 
Stillman,  Dr.  C.   F.,  sector  splint, 

373 

— ,  brace    for  hip   and   pelvic   de- 
formities, 375 

Subtrochanteric  osteotomy,  400 

Sympathetic  hips,  25 

Symptoms  of  sprain,  52 

—  of  second  stage,  248 

—  of  chronic  rheumatic  arthritis, 

Qi 

—  of  first  stage,  239 

—  of  synovitis,  121 
Synovial  membrane,  44 

—  fluid,  44 

—  membrane,  as  primarily  affected 
in  ostitis,  172 

Synovitis,  acute  primary,  121 

—  diagnosis  of,  128 

—  duration  of,  133 

—  symptoms  of,  121 

—  treatment  of,  131 

—  prognosis  of,  128 

—  rarely   ends   in   chronic  joint- 
disease,  125 

Syphilis  as  related  to  bone-disease, 

208 
Taylor,  Dr.  C.  F.,  hip-splints,  362- 

8-9 
— ,  practice  of,  360 


Taylor,  Dr.  R.  W.,  on  syphilitic 
ostitis,  143 

— ,  syphilis  as  related  to  bone-dis- 
ease, 208,  211 

Thomas,  Mr.  Hugh  Owen,  splint 
for  "hip-disease,"  349 

— ,  method  of  examination,  275 

Traction  in  articular  ostitis,  some 
facts  concerning,  359 

Traumatism,  its  influence  in  induc- 
ing exacerbations,  244 

— ,  its  relation  to  bone  disease,  207 

Traumatic  diastasis,  infrequency 
of,  140 

Treatment  of  articular  ostitis,  re- 
sults of,  by  the  Thomas  method, 
356 

—  of  chronic  articular  ostitis  by 
drilling  trochanter,  388 

—  of  articular  ostitis,  conclusions, 
386 

—  of  bursitis,  114 

—  of  diastasis.  151 

—  of  epiphysitis,  146 

—  of  neuroses,  69 

—  of  periostitis,  160 

—  of  periarthritis,  107 

—  of  rheumatism,  85 

— ,  results  of,  by  the  long  splints, 
380 

—  of  chronic  rheumatic  arthritis,  92 

—  of  sprains,  56 

—  of  synovitis,  131 

Treves,  Mr.  Frederick,  on  the  rela- 
tionship between  struma  and  tu- 
bercle, 204 

Trochanter,  drilling  of,  388 
Tubercle  as  related  to  struma,  204 
Types,   irregular,    infrequency   of, 

239 
Ulceration  of  arteries  complicating 

articular  ostitis,  266 
Vance,  Dr.  Ap  M.,  leather  splint, 

345 

Volkman's  case  of  ostitis  of  the  hip, 
1 86 

—  case  of  ostitis  with  exfoliation  of 
cartilage,  191 

—  subtrochanteric  osteotomy.  400 
Washburn,  Dr.,  hip-splint,  359 
Welch,  Dr.  Wm.  H.,  on  the  pathol- 
ogy of  strumous  ostitis,  189 

Welch,  Dr.  Wm.  H.,  report  on 
round-celled  sarcoma,  164 


4io 


SUPPLEMENTARY  INDEX  FOR  CASES. 


Willard,  Dr.  de  F.,  case  of  "hip- 
joint  disease,"  death  in  early 
stage,  175 

Wire-cuirass  after  excision,  396 
Wire-gauze  splint  of  Dr.  Hamilton, 

344 

Wrenches  for  orthopedic  appli- 
ances, 350 


Wright,  Mr.  Geo.  Arthur,  on  the 
importance  of  recognizing  the 
initial  lesion,  270 

Wyeth,  Dr.  John  A.,  the  combina- 
tion method,  367 

Yale,  Dr.  Leroy  M.,  on  excisions, 
390 


SUPPLEMENTARY  INDEX  FOR  CASES. 


Articular  Ostitis  with  arterial  hem- 
orrhage complicating,  266 
diagnosticated   as  synovitis, 

293 

and  Pott's  disease,  diagnosti- 
cated as  Rheumatism,  303 

illustrating  diagnosis  of,  277 

simulating  sprain,  279 

with  a  rheumatic  history,  281 

with  a  long  remission — au- 
topsy, 182 

responding  to  faith-cure  (?), 

231 

,  multiple,  198 

illustrating  slow  evolution, 

228 

with  two  and  a  half  years' 

interval  between  invasion  and 
second  stage,  228 

after  typho-malarial  fever, 

214 

from  acquired  struma,  214 

in  a  family  of  hip  cases,  235 

treated  expectantly;  excellent 

result,  326 

treated  by  a  long  splint;  ex- 
cellent result,  328 

treated  expectantly;  poor  re- 
sult, 332 

treated  by  the  physiological 

method;  fair  result,  338 

double,  treated  expectantly  ; 

bad  result,  334 

treated  by  physiological 

method  ;  result,  lardaceous  de- 
generation, 341 

double,  treated  by  physio- 
logical method  ;  fair  result,  340 


Articular  Ostitis  treated  expectant- 
ly; good  result,  329 

treated  expectantly — death  ; 

autopsy,  331 

treated  expectantly  ;  fair  re- 
sult, 329 

treated  by  physiological 

method  ;  result  dislocation  and 
death,  342 

with  lardaceous  degenera- 
tion; excised;  recovery,  391 

,  excision;  lardaceous  degen- 
eration three  years  later;  death; 
autopsy,  394 

Amyloid  or,  Lardaceous  Degenera- 
tion, cured  by  dislocation,  265 

Bursitis  long  regarded  as  "hip- 
disease,"  in 

—  with  a  peculiar  click,  113 

— ,  gluteal;  recovery,  112 

Contusion,  to  illustrate  diagnosis 
of  articular  ostitis,  279 

— ,  with  obturator  nerve  paralysis; 
recovery,  51 

— ,  result  of  fall  from  great  height; 
perfect  recovery,  55 

Caseous  Ostitis,  illustrating  in- 
fluence of  heredity,  216 

,  specimen  showing  third  stage 

changes,  192 

Chronic  Articular  Ostitis  beginning 
as  synovitis,  173 

with     a    peculiar    neurosis, 

65 

Diastasis  (?),  138-9 
— ,  traumatic,  147 
Dislocation,  diagnosticated  as  as- 

titis,  218 


SUPPLEMENTARY  INDEX  FOR  CASES. 


Dislocation,  congenital,  150 

— ,  traumatic,     diagnosticated    as 

"hip-disease,"  317 
Epiphysitis,  acute,  with  specimen, 

136 

—  of  syphilitic  (?)  origin,   137 

—  with  bony  repair  and  shorten- 
ing, 141 

Fracture  of  thigh,  incomplete,  upper 
fourth,  joint  unimpaired,  56 

Femoral  disease  in  one  hip,  aceta- 
bular  in  the  other,  177 

Femoral  abscess  from  Pott's  dis- 
ease, diagnosticated  as  "hip- dis- 
ease," 313 

Iliac  abscess,  101 

Ilio-psoas  Bursitis,  ending  in  joint- 
disease,  117 

Infantile  Paralysis,  diagnosticated 
as  articular  ostitis,  286 

Judson,  Dr.,  three  cures  reported, 
383 

Lardaceous  disease  of  ten  years' 
standing,  267 

predicted  by  specific  gravity 

of  urine,  266 

arrested  by  amputation,  394 

Neurosis  to  illustrate  diagnosis  of 
articular  ostitis,  284 

—  simulating   spinal    caries,    long 
remissions,  62 

—  of  both  hips,  diagnosticated  as 
bone-disease,  61 

—  with  marked  neurotic  diathesis, 
66 

—  complicated     by    periarticular 
swelling,  67 

—  complicated   by  inguinal  aden- 
itis, 70 

—  of     long     standing     promptly 
cured  by  blistering  and  poultic- 
ing, 69 

Necrosis  of  Ilium,  104 
Ostitis  or  Diastasis,  149 
— ,  syphilitic,  210 
— ,  chronic    articular   without    at- 
rophy, 232 

—  of  the  hip  with  recurring  naso- 
facial  erysipelas,  215 

—  in  the  wake  of  pertussis,  213 

—  with    spontaneous    dislocation, 
262 

—  with  resistance  only  to  abduc- 
tion and  rotation,  236 


Ostitis,  second   stage,  precipitated 

by  trauma,  244 
— ,  illustrating  passage  from  first  to 

second  stage,  246 
— ,  progress  interrupted,  243 

—  of  the  hip   to  illustrate  second 
stage,  240 

—  with  abscess,  disappearing,  258 
—  speedily  reaching  second  stage, 

246 

—  reaching  second  stage  after  first 
exacerbation,  253 

—  with  progress  very  nearly  pain- 
less, 248 

—  cured  in  third  stage,  252 

—  illustrating  third  stage,  252 
Periostitis,  153 

— ,  closely  simulating  "  hip-dis- 
ease," 158 

—  near  sacro-iliac  junction,  156 

—  illustrating  diagnosis,  156 

—  following  a  cellulitis,  156 

—  with   necrosis,  154 

—  resulting  in  shortening,  155 

—  to  illustrate  diagnosis  of  articu- 
lar ostitis,  295 

Perityphlitis,  309 

Periarthritis  suppurative  with  fatal 
result;  autopsy,  95 

— ,  phlegmonous,  with  resolution, 
98 

— ,  with  glandular  suppuration,  99 

— ,  with  extensive  suppuration;  re- 
covery, 97 

— ,  chronic  rheumatic,  with  exacer- 
bations, 80 

—  Coxo-femoral,  94 

—  simulating  psoas  abscess,  108 

—  illustrating  diagnosis,  99 

—  with  complicating  neurosis,  101 
— ,  fatal;  exhaustion,  108 

—  resulting  in  bone  disease,  103 

—  with  signs  of  ostitis,  100 

—  diagnosticated  as  "hip-disease," 
289 

Perinephritis,  306 

Pott's    disease    diagnosticated    as 

articular  ostitis,  301 
Reported  by  Dr.  C.  F.  Taylor,  381 
Rheumatism   diagnosticated    from 

family  history,  282 

—  treated  for  "hip-disease,"  74 

—  to  illustrate  diagnosis  of  articu- 
lar ostitis,  281 


412 


SUPPLEMENTARY   INDEX   FOR  CASES. 


Rheumatism,  muscular,  with  typi- 
cal "  hip-limp,"  75 

—  treated  by  free  passive  motion, 
86 

—  with  relapses,  77 
Rheumatic  Arthritis,  chronic,  with 

great  atrophy,  87 

with  marked  periarthritis,  88 

attributed  to  the  wearing  of 

a  truss,  90 
complicated    by  suppurative 

periostitis,  83 

complicated  by  chorea  minor, 

-    84 

of    knee   simulating  ostitis, 

82 
of  hip,  following  polyarticular 

rheumatism,  79 
relieved  by  passive   motion 

under  ether,  93 
Rheumatic  periarthritis,  318 
Sprain   to   illustrate    diagnosis    of 

ostitis,  278 

—  marked    by   exacerbations  and 
remissions,  and  malingering,  54 


Sprain  and  contusion  in  adult,  52 

—  in    young    child    of    strumous 
family,  57 

—  with   signs  of  ostitis;  recovery 
perfect,  53 

—  with  fixation  of  hip,  53 
Sacro-iliac  disease,  299 

—  (?)  error,  104 

Synovitis,  acute,  with  very  sudden 
invasion,  cure  not  perfect,  127 

—  with   surface  temperature  low- 
ered, 124 

— ,  acute  primary,  121 

—  illustrating  permanency  of  cure, 

IS* 

—  of  both  hips,  132 

—  recovering  under  liniment  and 
roller,  133 

—  illustrating  clinical  history,  125 
Syphilitic  epiphysitis,  143 
Suppuration  about  sacro-iliar  junc- 
tion from  retained  tent,  106 

Showing    positions    after   cure    ir 

third  stage.  254 
Sarcoma,  periosteal,  162 


Date  Due 


PRINTED   IN   U.S.A.  CAT.     NO.     24      161 


A  nnn  I   '''"llf/ll 


WE855 


Gibney,  Virgil  P. 

an*  its  dijeases 


1883 


WE855 


1883 
Gibney,  Virgil  P. 

Hip  and  its  diseases 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


mmm* 


3  :?mm 


SlH 


